Columbia  Mmbersiitp 

^tljool  of  IBental  anb  (0ral*  burger? 


^dtxmtt  %ihvavv 


--  /-' 


ELECTRO- H^MOSTASIS 


IN 


OPERATIVE  SURGERY 


BY 
ALEXANDER  J.  C.  SKENE,  M.D.,  LL.D. 

Professor  of  Gynecologj'  in  the  Long  Island  College  Hospital,  Brooklyn,  N.  V.  :  formerly  Professor  of 

Gynecology  in  the  Xew  York  Post-Graduate  Jledical  School:   Gynecologist  to  the  Long  Island 

College  Hospital ;  President  of  the  American  Gynecological  Society,  1SS7  ;  Corresponding 

Member  of  the  British,  Boston,  and  Detroit  Gynecological  Societies,  of  the  Royal 

Society  of  Medical  and  Natural  Sciences  of  Brussels,  of  the  Obstetrical  and 

Gynecological  Society  of  Paris,  and  of  the  Leipzig  Obstetrical  Society; 

Honorary  Member  of  the  Edinburgh  Obstetrical  Society  :  Fellow 

of  the  New  York  Academy  of  Medicine;  ex-President  of  the 

Medical  Society  of  the  County  of  Kings;  ex-President 

of  the  New  York  Obstetrical  Society 


BOSTON 

SHERMAN,  FRENCH  Is  COMPANY 

1910 


^.  V 


V 

^ 


TO 

JOHN    BYRNE,   M.  D.,   LL.  D.,   M.  R.  C.  S.  E., 

AS    AN    ACKNOWLEDGMENT    OF    HIS 

ORIGINAL    AND    MOST    VALUABLE    CONTRIBUTIONS   TO 

THE     SCIENCE    AND     ART     OF     THE    ELECTRIC     CAUTERY     IN     SURGERY  ; 

HIS    SUPREME    PROFESSIONAL    HONOR,   HONESTY,  AND    COURTESY  ; 

AND    IN    PERSONAL    GRATITUDE    FOR 

HIS  TRUE  AND  CONSTANT  FRIENDSHIP, 

THESE    PAGES    ARE    INSCRIBED    BY 

THE     AUTHOR. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/electrohaemostaOOsken 


PREFACE 


This  contribution  relating  to  electro-hsemostasis  and  the 
electric  cautery  in  general  and  special  surgery,  is  issued  to 
supplement  the  third  edition  of  my  work  on  diseases  of 
women,  in  which  the  subject  was  referred  to,  but  altogether 
too  briefly  discussed. 

The  interest  manifested  by  the  profession  in  this  sub- 
ject, the  employment  of  the  new  methods  of  operating  in 
other  than  gynaecological  surgery,  a  number  of  recent  im- 
provements in  instruments  and  in  the  technique  of  oj^era- 
ting,  and  a  larger  experience  confirmatory  of  the  value  of 
the  principles  and  practice  advocated,  both  prompted  the 
undertaking  and  raise  the  hope  that  the  results  will  be 
acceptable  to  the  profession. 

The  part  of  the  work  devoted  to  electro-hsemostasis  may 
appear  to  be  rather  aggressive,  not  to  say  revolutionary,  and 
therefore  it  might  be  judicious  to  give  in  this  preface  a 
statement  explanatory  of  the  principles  involved  and  a 
preliminary  argument  in  their  favor;  but  past  experiences 
remind  me  that  it  is  unnecessary  to  do  so. 

In  former  contributions  to  medical  literature  I  have 
avoided  all  declamations  and  special  pleadings  regarding 
the  merits  of  that  which  I  had  to  offer,  in  order  that  I 
should  have  the  opinion  of  the  profession  to  guide  me  to 
rational  conclusions  regarding  the  value  of  my  work. 


vi  PREFACE. 

Having  fared  well  in  tLe  past,  I  am  perfectly  satisfied 
to  leave  the  present  effort  to  tlie  judgment  of  those  for 
whom  these  pages  were  written — the  thinking,  reading, 
working  members  of  the  medical  profession. 

My  grateful  acknowledgments  are  due  to  Dr.  R.  L. 
Dickinson  for  taking  charge  of  the  illustrations,  which 
speak  for  themselves ;  to  Dr.  W.  H.  Seymour  for  his  val- 
uable laboratoiy  work  and  demonstrations  of  the  process 
of  electro-hsemostasis  ;  and  to  Louis  M.  Pignolet,  the  maker 
of  the  electrical  instruments. 


CONTENTS 


CHAPTER  PAGE 

I. — IXTRODUCTIOX 1 

IT. — Descriptiox  of  ixstbuments 9 

III. — Results  of  this  hemostatic  process 21 

IV. — Electro-hemostasis  in  ovariotomy 30 

Y. — ElECTRO-H.EMOSTASIS    in   myomectomy    and    abdominal    HY'STERECTOMY  39 

VI. — Electro-h^emostasis  in  OVARIO-SALPINGECTOMY 49 

VII. — Electro-h^mostasis  in  appendectomy 57 

VIII. — Treatment    of    cancer    of   the    uterus   by'   the  electro-cautery 

and  hemostasis 65 

IX. — The  electro-cautery   in   the   treatment   of   pelvic  abscess   and 

diseases  of  the  vulva  and  vagina 85 

X. — Electro-hemostasis   in    extirpation   of   the    mammary^   and   lym- 
phatic  GLANDS 95 

XL — ElECTRO-H^EMOSTASIS    in    extirpation    of    tumors    of    the    BLADDER      .  102 

XII. — The  electro-cautery  in  the  treatment  of  urethral  affections.  113 

XIII. — Electro-h.emostasis  in  the  treatment  of  rectal  hemorrhoids    .  120 
XIV. — The  treatjient  of  neoplasms  of  the  skin  and  mucous  membranes 

with  the  electro-cautery  and  electrolysis         ....  129 

XV. — Asepsis  and  antisepsis  in  surgery 136 

XVI. — Asepsis  and  antisepsis  (continued) 156 


LIST   OF   ILLUSTRATIONS 


NO.  PAGE 

1.  Electro-haemostatic  forceps 9 

2.  Electro-haemostatic  forceps  chamber 10 

3.  Electro-haemostatic  forceps  chamber 10 

4.  Transformer 11 

5.  Flexible  cable 12 

6.  Portable  storage  battery 14 

7.  Use  of  alternating  street  current  . 15 

8.  Use  of  continuous  street  current 16 

9.  Portable  battery  with  amperemeter 17 

10.  Artery,  treatment  of 19 

11.  Artery,  macroscopic  appearance 21 

12.  Artery,  macroscopic  appearance 22 

13.  Artery,  macroscopic  appearance 22 

14.  Artery,  microscopic  appearance 24 

15.  Artery,  microscopic  appearance .         .         .24 

16.  Fallopian  tube,  macroscopic  appearance 26 

17.  Fallopian  tube,  macroscopic  appearance 27 

18.  Omental  adhesions 31 

19.  Artery  forceps 32 

20.  The  dome 32 

21.  Visceral  protection  during  treatment 33 

22.  Intestinal  adhesion .         .         .        .34 

23.  Shield  forceps  for  laparotomy 35 

24.  Small  pedicle  forceps  for  ovariotomy 35 

25.  Large  pedicle  forceps 36 

26.  Pedicle,  treatment 37 

27.  Pedicle  of  fibroid,  treatment 39 

28.  Sessile  fibroid,  incisions 40 

29.  Sessile  fibroid,  cuff  of  peritoneum 40 

30.  Dome  controlling  haemorrhages 41 

31.  Steps  in  treating  stump  in  myomectomy 42 

32.  Treatment  of  broad  ligament .         .43 

33.  Treatment  of  broad  ligament 44 

34.  Final  treatment  of  vessels 45 

35.  Use  of  dome  in  sac  of  Douglas 47 

36.  Removing  tube  and  ovary 54 

37.  Removing  tube  and  ovary 55 

38.  Seizure  in  appendectomy 61 

39.  Treatment  of  mesentery 62 


X  ELECTRO-H^MOSTASIS   IN   OPERATIVE  SURGERY. 

NO.  PAGE 

40.  Second  seizure  in  appendectomy 63 

41.  Stump  after  appendectomy .63 

42.  Epithelioma  of  cervix 66 

43.  Epithelioma  of  cervix 66 

44.  Byrne's  speculum 67 

45.  Byrne's  speculum  in  position  .        .         .         .        .         .        .         .         .68 

46.  Byrne's  cautery  loop 69 

47.  Byrne's  special  loop  carrier 70 

48.  Passing  loop  around  tumor 71 

49.  Diverging  volsellum 73 

50.  Cautery  knife 72 

51.  High  amputation  of  cervix =        ...  73 

53.  High  amputation  of  cervix .                 .        .  73 

53.  High  amputation  of  cervix .        ,         .        .  74 

54.  Cervix  excised 75 

55.  Dome  electrode .     '    .  75 

56.  High  amputation  of  cervix     .         .        . 76 

57.  Stump  after  removal  of  cervix 77 

58.  Cautery  incision  in  vagina 77 

59.  Elytrotomy 78 

60.  Hysterectomy,  treating  broad  ligament 79 

61.  Diagram  of  seizures  in  hysterectomy .79 

63.  Shield  forceps  for  vagina 80 

63.  Hysterectomy,  treating  broad  ligament 80 

64.  Hysterectomy,  treating  ovary  and  tube 81 

65.  Peritoneal  sutures 83 

66.  Peritoneal  sutures  tied 83 

67.  Pedunculated  tumor  of  bladder .  105 

68.  Protecting  bladder  wall 106 

69.  Treating  urethral  gland 116 

70.  Treating  urethral  gland 117 

71.  Ha?morrhoidal  clamp .131 

73.  Operation  for  hiemorrhoids 133 

73.  Operation  for  haemorrhoids 133 

74.  Dickinson's  oblique  seizure  of  haemorrhoids 134 

75.  Treating  fissura  in  ano 137 

76.  Ordinai'y  window  frame 144 

77.  Improved  window  frame 145 

78.  Ordinary  door  frame 146 

79.  Improved  door  frame 147 

80.  Improved  door  frame  with  wood  trimming 148 

Plate  I — Reorganization  of  stump         . facing  36 

Plate  II — Reorganization  of  stump 28 


ELECTRO-H^MOSTASIS 
IN    OPERATIVE    SURGERY 


CHAPTER  I 

I  N  T  E  O  D  U  C  T I  0  N 

In  looking  backward  upon  tlie  evolution  of  surgical 
lisemostasis,  one  of  the  most  agreeably  surprising  steps  ob- 
served in  the  progress  toward  the  ideal  is  the  discovery 
that  an  aseptic  ligature  can  be  inclosed  in  the  tissues  with- 
out disturbing  the  healing  process.  Catgut  ligatures,  prop- 
erly prepared  and  sterilized,  soon  answered  all  the  require- 
ments of  the  surgeon  in  so  many  operations  that  he  has 
been  disposed  since  then  to  rest  satisfied  in  the  belief  that 
the  ideal  method  had  been  attained,  so  vastly  superior  was 
the  new  way  to  the  old.  Even  at  the  present  time  one  is 
liable  to  be  considered  hypercritical  and  fastidious  if  he 
questions  the  utility  and  competence  of  the  surgery  of  the 
day  in  controlling  haemorrhage  in  incised  wounds.  Never- 
theless, the  modern  ligature  has  its  defects  and  failings 
when  employed  in  certain  operations  and  in  some  con- 
ditions. 

Some  of  those  who  first  used  catgut  as  a  ligature  ac- 
knowledge that  it  is  difficult  to  sterilize  and  keep  perfectly 
clean,  and  that  it  is  not  altogether  reliable  in  ligating  blood 
vessels  in  the  pedicle  of  an  ovarian  tumor,  for  example 
More  recently  it  has  been  discovered  that  it  is  objection 
able  in  wounds  which  are  septic  or  contain  necrotic  tissue 
Take,  for  example,  a  suppurating  ovarian  tumor  or  a  pyo 
salpinx :  the  broad-ligament  pedicle  is  nearly  always  sep 


2  ELECTRO-H^MOSTASIS  IN   OPERATIVE   SURGERY. 

tic,  and  no  matter  how  clean  the  ligature  may  be  when 
applied  it  soon  becomes  contaminated  by  contact  with  the 
diseased  tissue,  and,  being  dead  animal  tissue,  it  adds  of  its 
own  seK  to  the  field  for  the  culture  of  bacteria.  A  ligature 
thus  contaminated  is  not  absorbed,  but  acts  as  a  foreign 
body  for  the  promotion  of  evil  and  the  interruption  of  the 
process  of  repair,  and  is  responsible  for  the  bad  results 
which  have  sometimes  followed  when  I  had  operated  ac- 
cording to  all  the  rules  of  modern  surgery.  Others  have 
had  similar  failures  from  the  same  cause,  if  I  may  judge 
from  cases  which  have  come  to  my  notice.  On  this  account 
catgut  is  the  worst  material  that  can  be  left  in  a  wound 
which  is  not  perfectly  free  from  germs  of  disease.  Of  minor 
importance,  but  still  worthy  of  notice,  is  the  fact  that  dry 
catgut  is  not  very  flexible  and  easily  handled,  and  if  softened 
by  immersion  in  a  sterilized  or  antise^Jtic  solution  it  stretches 
or  breaks,  and  can  not  be  depended  upon  to  close  vessels 
and  hold  them.  This  tendency  to  stretch  is  increased  by 
the  softening  which  takes  place  while  the  ligature  is  in  the 
tissues,  and  therefore  haemorrhage  may  occur.  This  has 
happened  in  abdominal  operations,  and  on  that  account 
many  operators,  even  in  the  early  days  of  modern  surgery, 
preferred  silk  ligatures  for  much  of  their  work. 

If  I  mistake  not,  the  majority  of  surgeons  at  the  pres- 
ent time  use  silk  ligatures  in  ovariotomy,  hysterectomy,  and 
similar  operations  ;  and  yet  the  silk  ligature  does  not  meet 
all  the  demands  of  surgery.  The  objectionable  features  of 
silk  are,  that  it  is  not  absorbed  bat  remains  in  the  tissues 
where  it  is  placed,  quiescent  in  many  cases,  but  occasion- 
ally causing  much  mischief.  The  unfavorable  behavior  of 
the  silk  ligature  has  been  so  fully  recognized  by  some  of 
the  leading  surgeons  that  they  have  raised  the  question 
whether  this  non-absorbable  ligature  should  ever  be  used 
in  abdominal  surgery.  Judging  from  my  own  limited  ob- 
servations and  the  meager  records  found  in  surgical  litera- 
ture on  this  subject,  it  appears  that  silk  ligatures  either 
become  encysted  and  remain  where  they  are   placed,  or, 


INTRODUCTION.  3 

becoming  freed  from  the  protecting  exudate,  wander  about 
until  they  are  thrown  out  by  the  eliminative  process  of 
suppurative  or  ulcerative  inflammation. 

Fine  ligatures  of  silk  applied  to  small  blood  vessels  in 
areolar  and  muscular  tissue  become  walled  in  with  repara- 
tive exudates  and  may  remain  indefinitely,  but  those  used 
in  abdominal  operations  are  likely  to  work  their  way  out 
through  the  skin  or  escape  into  some  neighboring  viscus. 
Under  favorable  circumstances  the  harmful  action  of  silk 
ligatures  has  escaped  observation,  owing  to  the  fact  that 
they  cause  no  trouble  until  long  after  recovery  from  the 
operation  in  which  they  were  employed.  If  the  silk  is 
clean  when  used,  no  immediate  disturbance  of  the  jDrocess 
of  healing  is  caused,  and  so  far  silk  appears  to  be  a  perfect 
agent ;  still,  it  is  not  so,  for  the  necessary  walling  in  of  a 
silk  ligature  requires  more  time  than  the  disposal  of  an 
absorbable  ligature,  and  the  quantity  of  new  material  left 
in  the  wound  surrounding  the  ligatures  retards  the  process 
of  repair.  On  this  account  the  tissues  in  the  neighborhood 
of  the  wound  remain  indurated,  and  do  not  regain  their 
elasticity  and  freedom  from  tenderness  for  a  long  time,  even 
when  union  takes  place  promptly  and  without  sujipuration. 

These  facts  regarding  the  slow  recovery  or  repair  caused 
by  the  presence  of  silk  in  the  tissue,  and  the  disposition  of 
such  ligatures  to  be  thrown  out  in  course  of  time,  are  illus- 
trated in  an  extirpation  of  the  mammary  gland  which  occurred 
in  ray  practice.  The  patient  being  spare  of  habit  and  to  a 
slight  degree  hsemorrhagic,  more  ligatures  were  required  than 
usual,  and  all  of  the  fine  silk  on  hand  was  used  up,  and  so 
one  ligature  of  thick  silk  had  to  be  used.  Healing  took 
place  without  delay,  but  the  tissues  remained  indurated  and 
irregular,  and  fixed  to  the  wall  of  the  thorax  for  a  long 
time.  There  were  also  slight  pains  at  times  and  tender- 
ness. Two  years  afterward  the  patient  returned  for  advice 
regarding  an  inflamed  part  about  an  inch  in  diameter,  pre- 
senting all  the  signs  of  a  small  abscess,  situated  about  an 
inch  and  a  half  from  the  original  incision.     The  parts  were 


4  ELBCTRO-H^MOSTASIS  IN   OPERATIVE   SURGERY. 

incised  and  a  mass  of  exudate  or  scar  tissue  remov^ed  with 
a  curette.  In  this  mass  I  found  the  large  ligature  which 
I  had  used  in  operating.  The  silk  was  in  a  state  of  good 
preservation,  and  only  the  short  ends  of  the  ligature  pro- 
truded from  the  mass  in  which  the  ligature  was  imbedded. 
The  patient  rapidly  recovered,  and  there  was  no  return  of 
the  cancer  one  year  and  a  half  afterward.  This  shows 
that  the  whole  trouble  came  from  the  ligature  and  not 
from  the  recurrence  of  the  disease. 

Were  this  all  of  the  evil  that  can  be  charged  fairly 
against  the  silk  ligature  one  might  rest  satisfied,  but 
worse  follows  the  use  of  ligatures  of  all  kinds  in  abdom- 
inal and  pelvic  surgery.  Ligatures  apj)lied  to  the  broad- 
ligament  pedicles  of  ovarian  tumors  and  Fallopian  tubes 
are  guilty  of  much  wrong-doing.  For  example,  unless 
the  conditions  are  unusually  favorable,  the  pedicle  of 
an  ovarian  tumor  can  not  be  tied  tightly  enough  to  close 
the  arteries  in  the  way  that  surgeons  say  they  should  be 
ligated  to  make  sure  of  controlling  haemorrhage  with  cer- 
tainty. There  is  a  liability,  in  thick  pedicles,  for  the 
tissues  to  shrink  under  the  pressure  of  the  ligature  and 
permit  the  vessels  that  have  been  temporarily  closed  to  open 
again  and  allow  bleeding  to  take  place.  This  inefficiency 
of  the  silk  ligature  has  been  observed  by  Dr.  Howard  A. 
Kelly,  so  that  he  has  adopted  the  method  of  ligating  the 
pedicle  in  two  sections,  by  including  the  ovarian  arteries 
in  one  ligature  and  the  tubal  and  uterine  side  of  the 
pedicle  in  the  other,  and  in  addition  to  that  he  also  ligates 
the  larger  vessels  in  the  end  of  the  stump. 

Whenever  the  tissues  of  the  pedicle  are  rendered  friable 
by  disease  or  degeneration,  it  is  well-nigh  impossible  to  con- 
trol haemorrhage  with  a  ligature  of  any  kind.  Silk  is  as 
bad  as  or  worse  than  anything  else,  for  it  cuts  the  tissues  if 
tied  as  tight  as  possible  without  breaking. 

These  are  some  of  the  charges  which  can  be  brought 
fairly  against  the  silk  ligature  as  a  means  of  immediately 
and  permanently  arresting  haemorrhage.     The  subsequent 


INTRODUCTION. 


behavior  of  the  ligature,  and  the  character  of  the  stump  to 
be  repaired  after  ligation,  are  still  more  unsatisfactory  to 
both  the  patient  and  the  surgeon.  The  pressure  of  the 
ligature  upon  the  nerve  tissue  and  the  traction  of  the  parts 
toward  the  point  of  constriction,  especially  in  a  short, 
broad  pedicle,  cause  irritation  and  pain.  There  is  a  large 
mass  of  tissue  projecting  beyond  the  ligature  which  has  to 
be  disposed  of  by  a  process  of  degeneration  and  absorp- 
tion ;  the  ligature  and  the  tissue  of  the  pedicle  beneath  it 
have  to  be  closed  in  by  a  deposit  of  plastic  material,  which 
in  time  is  disposed  of  by  absorption,  and  the  ligature  set 
fi'ee.  During  all  these  weeks  or  months  required  to  com- 
pletely repair  the  stump  there  is  oftentimes  considerable 
pain  and  distress  in  the  site ;  nothing  dangerous  or  alarm- 
ing but  annoying.  Not  infrequently  when  a  diseased  Fallo- 
pian tube  forms  part  of  the  pedicle  there  is  a  secondary 
attack,  maybe  several,  of  inflammation  in  the  stump,  caused 
by  the  tube  remaining  open  and  giving  out  septic  material. 
These  sequelae  have  passed  unnoticed  by  many  surgeons, 
and  are  lightly  spoken  of  by  others,  presumably  because 
there  was  no  danger  to  the  life  of  such  patients ;  but  the 
best  operators  have  given  attention  to  the  subject,  and, 
having  watched  their  results  with  scientific  accuracy,  have 
observed  these  results  and  recorded  them. 

What  becomes  of  silk  ligatures  that  are  left  in  the 
peritoneal  cavity  is  a  question  of  vast  importance.  One 
opinion  which  for  a  long  time  prevailed  was  that  a  silk 
ligature  applied  to  a  broad-ligament  pedicle  becomes  en- 
cysted and  remains  quiescent  for  all  time.  Exceptions  to 
this  rule  were  admitted,  and  were  accounted  for  by  some 
unclean  operating  or  a  septic  ligature  that  caused  suppura- 
tive inflammation  in  the  stump  by  which  the  ligature  was 
set  free  or  found  its  way  into  some  neighboring  viscus. 
This  is  almost  altogether  incorrect.  Occasionally  it  may 
happen  that  a  ligature  becomes  firmly  fixed  to  the  broad 
ligament  by  an  exudate  and  remains  imbedded  for  all  time, 
but  that,  I  believe,  is  the  exception,  not  the  rule. 


6  ELEOTRO-H^MOSTASIS  IN  OPERATIVE   SURGERY. 

This  very  interesting  question  of  tlie  disposal  of  silk 
ligatures,  as  a  rule,  has  not  yet  been  answered  fully,  so  far 
as  I  can  ascertain.  Guided  by  my  own  experience,  I  be- 
lieve, as  already  stated,  that  ligatures  left  in  the  peritoneal 
cavity  are  at  first  encysted  and  finally  liberated,  and  remain 
in  the  peritoneum  or  escape  through  some  of  the  viscera  or 
the  abdominal  wall.  So  many  cases  of  this  kind  have  been 
reported  that  I  need  say  nothing  on  that  subject,  except 
that  they  make  their  exits  by  being  first  set  fi'ee  fi'om  the 
plastic  stuff  that  surrounds  them  and  travel  outward  by  a 
pi'ocess  of  ulceration  or  suppuration  and  necrosis  of  the 
tissues  in  the  way  of  their  outgoing.  At  least  that  is  the 
way  of  it  according  to  my  own  observations. 

By  way  of  illustrating  what  has  been  said  about  liga- 
tures being  set  free  in  the  peritoneal  cavity,  I  give  the 
history  of  a  specimen  brought  to  my  clinic  at  the  New 
York  Post-Graduate  School  by  Prof.  F.  Ferguson.  The 
patient  from  whom  the  specimen  was  obtained  died  of  some 
thoracic  disease,  and  while  making  the  autopsy  Professor 
Fero;uson  learned  that  she  had  had  her  ovaries  and  tubes 
removed  about  one  year  prior  to  her  death.  The  pelvic 
organs  were  removed  entire,  and  I  had  every  facility  for 
their  examination.  The  stumps  were  rounded  off  even 
with  the  posterior  surface  of  the  broad  ligaments,  showing 
that  all  that  portion  of  the  stumps  outside  of  the  ligature 
had  been  disposed  of,  and  also  the  exudate  that  had  been 
thrown  around  the  ligatures  to  inclose  them.  The  ends  of 
the  tubes  were  open.  The  ligatures  of  thick  silk  were 
found  in  the  most  dependent  part  of  the  sac  of  Douglas, 
quite  free  fi'om,  but  resting  upon,  the  thickened  peritoneum. 
The  thickening  of  the  peritoneum  in  the  sac  resulted  from 
cellular  proliferation  and  exudation,  jDOSsibly  brought  about 
by  irritation  arising  fi^om  the  presence  of  the  ligatures. 
What  would  have  become  of  the  ligature  finally,  if  the 
patient  had  lived,  I  know  not. 

From  among  a  number  of  cases  recorded  in  which  the 
ligature  migrated  I  give  the  following :  The  patient  had 


INTRODUCTION.  Y 

s,  severe  puerperal  peritonitis  followed  by  chronic  ovaritis 
and  varicose  veins  of  the  broad  ligaments.  This,  with  very 
extensive  old  adhesions  of  all  the  j^elvic  organs,  caused  so 
much  suffering  that  it  became  necessary  to  operate.  The 
tubes  and  ovaries  were  removed,  the  veins  closed,  and  ad- 
hesions separated.  One  ovary  and  tube  were  found  high 
up  and  held  in  this  abnormal  position  by  adhesions.  When 
these  were  ligated  and  removed  the  stump  rested  near  the 
lower  part  of  the  wound  in  the  abdominal  wall.  The 
recovery  was  quite  favorable,  but  about  two  months  after 
the  patient  was  dismissed  she  returned,  complaining  of 
pain  in  the  scar  near  its  lower  end.  The  scar  at  that  point 
was  stretched,  and  there  was  a  slight  protrusion,  not  un- 
like a  beo-innino;  hernia,  but  there  was  some  fluctuation  and 
flatness  on  percussion,  which  led  to  a  diagnosis  of  abscess. 
An  opening  was  made  and  a  small  amount  of  serum  and 
tissue  debris  escaped,  but  not  any  visible  pus.  The  sinus 
was  washed  out,  but  it  would  not  close.  A  little  serous  dis- 
charge continued  for  six  weeks  or  two  months,  when  she  re- 
turned for  treatment.  Suspecting  the  presence  of  a  ligature 
that  had  escaped  from  its  environing  exudate,  it  was  fished 
out  with  a  blunt  hook,  and  then  healing  soon  closed  the  sinus. 
Having  observed  these  disappointing  actions  of  liga- 
tures, I  naturally  looked  for  something  better  in  surgical 
hsemostasis.  This  I  found  in  the  work  of  Dr.  Thomas  Keith, 
who  taught  me  his  method  of  treating  the  pedicle  in  ovari- 
otomy by  the  clamp  and  cautery,  which  in  theory  and  prac- 
tice was  most  satisfactory.  No  doubt  this  feature  of  his 
operating  contributed  largely  to  making  him  the  most  suc- 
cessful ovariotomist  of  his  time.  The  experience  of  years 
and  a  large  number  of  operations  in  which  his  method  was 
used  has  fully  confirmed  my  confidence  in  this  way  of 
controlling  haemorrhage.  The  method  of  treating  the 
pedicle  of  ovarian  tumors  employed  by  Keith  and  his 
followers  was  never  adopted  by  surgeons  in  general.  This 
was  due,  apparently,  in  part,  to  ignorance  of  the  principles 
of  the  method,  but  more  especially  to  the  diflficulties  in  the 


8  ELECTEO-H^MOSTASIS   IX   OPERATIVE    SUR&ERY. 

tecliniqne  cf  tlie  procedure.  Many  belie\'ed.  and  still  be- 
lieve, tliat  it  wa.s  necessary  to  char  the  stump  with  the  cau- 
tery in  order  to  stijp  the  Ijleeding :  Ijiit  the  fact  is,  Keitli 
applieil  a  clamp  witli  Ijroad  jaws  to  the  pedicle  and  com- 
pressed it  strr^ngly.  an<l  then  apjdied  a  large  cauterv  iron 
to  the  upper  sifle  <ji  the  cktmp  until  the  instiTunent  was 
heateil  sufficiently  to  desiccate  the  tissues  and  not  to  char 
them.  This  required  much  time  and  lar2"e  experience  in 
handling  the  cautery  irr^n.  in  crder  tC)  rjl^tain  the  desTee  of 
heat  necessary  ami  t'j  kn^iw  the  length  of  time  it  should 
be  apjjlied.  In  other  words,  to  treat  a  bi'-o  ad -ligament 
pedicle  in  this  way  reijuired  a  knr.wledge  and  Judo-ment 
that  but  few  had  the  patience  to  acipdre. 

I  cijnfe-s  that  I  was  n'jt  sure  ijf  niv  wr»rk  in  mv  tirst 
operations,  and  sometimes  applied  a  light  li2"ature  to  feel 
safe  before  I  dared  return  the  stump  intu  the  abdominal 
cavity.  A^  hen  civarioti;any  Ijecame  impr-jved,  so  that  better 
results  Avere  oljtaineil.  anil  material  f':ir  ligatures  was  made 
aseptic  and  m<:ire  ay)prripriate.  I  gave  iij)  the  clam|:i  and 
catiterv  and  tised  the  ligattire  :  Ijiit  I  was  never  satisfied 
Avith  the  results,  and  earnestly  sijiight  to  overcome  the 
ob]ectii:in  to  the  clamp  and  heat  to  ci;»ntrrd  htemorrhage — 
namely,  the  application  ni  the  heat  ^uppl}'.  While  thiuk- 
ino;  of  h<jw  tij  riverci'jme  these  difficulties,  my  attention  was 
calleil  trj  the  tise  oi  electricity  in  heatiuo'  laundiy  smoothing 
irons.  It  then  <;iecurred  to  me  t'j  a<la}it  the  same  heating 
power  X'\'  -uroieal  instruments,  such  as  the  clamp  and  forceps. 

My  re<juirements  in  this  regard  were  exjdained  to  Mr. 
Louis  M.  Pio'nolet.  an  electrician,  who  has  given  much 
attenti'iin  t^  electricitv  as  tised  in  medicine  and  surgery. 
He  at  once  took  u|»  th^  -tudy  uf  the  subject  Avith  enthu- 
siasm, and  soon  |:iri>;lueed  the  in-truments  ami  a}:)pliances  re- 
(juired.  He  fir>t  made  an  artery  forceps,  then  a  clamp,  and 
linally  a  full  set  >:d  h,*mr)Stati(j  instruments.  I  should  say 
that  it  was  his  adaptation  -jf  the  -ysteni  of  electric  heating 
t(»  these  instruments,  wliich  enabled  me  to  employ  the 
method  for  the  cijntr<:il  <A  Ijleeiling  in  all  -urgical  operations. 


CHAPTER  II 


DESCRIPTIOX    OF   LXSTEOIEXTS 


The  followiug  description  of  the  instruments  is  given 
by  Mr.  Pignolet. 

In  tliese  forceps  tlie  lieat  is  generated  by  the  passage 
of  an  electric  current  thi'ougli  a  resistance  wii'e  in  a  cham- 
ber in  one  of  the  jaws,  for  it  has  been  found  to  be  suJfficient 
to  heat  but  one  of  them. 

The  method  of  heating  is  simple,  and  is  applicable  to 
forceps  of  various  forms  and  sizes  since  the  mechanism 
of  the  instrument  is  not  altered  by  the  electiical  attach- 
ments.    The  construction  is  shown  bv  the  illustrations,  of 


Avhich  Fig.  1  is  a  side  view  of  a  compression  forceps  heated 
on  this  pi'inciple.  Fig.  2  is  a  longitudinal  section,  and  Fig. 
3  a  top  view  of  the  heated  jaw  on  an  enlarged  scale,  with 
the  cover  D  and  the  insulatins;  material  6' removed. 

A  resistance  wire,  A^  is  located  at  the  bottom  of  the 
chamber,  close  to    the  face  of  the  jaw,  fi'om  which  it  is 


10 


ELECTRO-H^MOSTASIS  IN   OPERATIVE  SURGERY. 


insulated  by  a  thin  layer,  i?,  of  fireproof  material.  The 
chamber  above  the  wire  is  filled  with  an  electrical  insulator, 
Cj  which  is  also  a  non-conductor  of  heat,  such  as  asbestos, 
and  is  closed  water-tight  by  the  sheet-metal  cover  D.  One 
end  of  the  resistance  \vire  is  connected  to  the  jaw,  and  the 
other  to  an  insulated  copper  vdre,  E^  placed  in  a  metal 

tube,  F^  which   extends 
from  the  chamber  to  the 


fi    metal  block,  G^  attached 
to  the  handle  of  the  for- 


FiG.  2. 


ceps.  Here  the  copper  wire  is  connected  to  an  insulated 
terminal,  H,  mounted  in  the  block.  A  similar  terminal,  I^ 
is  attached  directly  to  the  block  and  is  uninsulated.  By 
this  method  of  construction  the  electrical  wires  are  incased 
in  metal,  so  that  the  forceps  can  be  sterilized  and  handled 
without  injury,  the  same  as  an  ordinaiy  instrument.  Start- 
ing at  the  insulated  terminal,  the  path  of  the  cuiTent  is 
through  the  copper  wire  and  the  resistance  wire  to  the 
tip  of  the  jaw,  thence  through  the  blade  of  the  forceps 
to  the  uninsulated  terminal.  The  copper  wire  and  the 
blade  of  the  forceps  form  a  path  of  good  electrical  conduc- 
tivity, and  are  consequently  but  very  slightly  heated  by  the 
passage  of  the  current  used.  On  the  other  hand,  the  wire 
in  the  chamber  is  a  poor  conductor,  and  is  heated  to  a 
greater  or  less  degree  according  to  its  resistance  and  the 
strength  of  the  current. 

The  electrical  energy  required  to  heat  the  forceps  varies 
from  ten  to  thirty-five  watts,  according  to  the  size  of  the 
instrument,  and  is  less  than  that  required  by  the  ordinary 
cautery  electrodes.  A 
storage  or  primary  bat- 
tery that  will  heat  the 
electrodes  will  gener- 
ally answer  for  the 
forceps ;  Ijut,  as  all  batteries  require  care  to  keep  them  in 
working  order,  the  use  of  the  electric  light  or  power  cur- 
rent from  a  dynamo  is  preferable  wherever  it  is  available. 


Fig. 


DESCRIPTION   OF  INSTRUMENTS. 


11 


The  dynamo  current  can  be  used  througli  a  controlling 
rheostat,  or,  if  the  current  be  alternating,  through  a  trans- 
former capable  of  furnishing  a  low  voltage  current  of  vari- 
ous strengths  and  pressui'cs  to  suit  the  different  forceps. 
A  special  advantage  of  the  transformer  is  that  the  cui-rent 
for  use  is  of  very  low  pressui'e,  and  is  generated  in  an  insu- 
lated coil  of  wire  by  the  inductive  action  of  the  dynamo 
current  which  flows  through  an  adjacent  coil.  If  the  wires 
or  connections  be  accidentally  touched,  nothing  is  felt  on 
account  of  the  low  pressure  of  the  transformer  current,  but 
with  a  rheostat  under  similar  conditions  a  disagreeable 
shock  might  be  experienced.     Furthermore,  the  insulation 


Fig.  4. 

between  the  two  coils  prevents  leakage  of  the  high-j^ressure 
current  to  the  low-pressure  circuit,  so  that  freedom  from 
shocks  is  insured.  If  the  djmamo  current  be  continuous, 
the  transformer  can  be  used  by  converting  the  continuous 
into  an  alternating  current,  by  means  of  a  small  rotary 
transformer. 

An  eflS^cient  and  convenient  type  of  transformer  is  rejDre- 
sented  by  Fig.  4.  It  will  furnish  current  for  heating  the 
forceps,  and  for  all  sizes  of  cautery  electrodes,  as  well  as 
for  lighting  small  incandescent  lamps.  The  pressure  and 
quantity  of  the  current  is  increased  by  moving  the  switch 


12 


ELECTRO-H^MOSTASIS  IN   OPERATIVE  SURGERY. 


arm  to  the  right  from  one  contact  button  to  the  next  until 
the  ]3roper  amount  is  obtained.  By  noting  the  contact  at 
which  the  desired  heat  is  developed  for  a  particular  for- 
ceps, the  switch  may  be  set  at  that  point,  and  the  forceps 
used  with  the  certainty  that  the  heat  will  be  suitable. 

As  shown  by  Fig.  5,  one  end  of  the  flexible  cable  for 
conveying  the  electric  current  to  the  forceps  is  inclosed  in 

a  soft  -  rubber  tube, 
and  is  provided  with 
two  hollow  metal 
sleeves,  Z  K,  which 
are  mounted  in  a 
piece  of  insulating 
material,  and  are 
adapted  to  slip  over 
the  two  terminals, 
I  IT,  of  the  forceps. 
Each  sleeve  is  insulated  from  the  other,  and  is  connected 
with  one  of  the  two  conductors  composing  the  flexible 
cable. 


Fig.  5. 


DIEECTIOlSrS    FOE    USINa   THE    ELECTRICAL    FORCEPS. 

The  method  of  arresting  haemorrhage  with  these  for- 
ceps consists  in  firmly  compressing  a  portion  of  the  bleed- 
ing tissues  or  the  end  of  a  vessel  between  the  jaws  of  the 
instrument,  in  order  to  expel  as  much  of  the  moisture  as 
possible,  and  then  desiccating  the  compressed  tissues  by 
heat  generated  in  the  jaws  by  the  electric  current.  In 
this  way  the  walls  of  the  arteries  become  united  and 
haemorrhage  is  effectually  prevented.  .  The  temperature 
required  for  desiccation  is  fi^om  180°  to  190°  F.,  which  is  not 
high  enough  to  char  or  burn  the  tissues,  but  simply  to 
desiccate  or  cook  them. 

The  forceps  are  sterilized  in  the  same  manner  as  the 
ordinary  instruments,  but  after  removal  from  the  sterilizer 
it  is  not  advisable  to  place  them  immediately  into  cold 
water,  while  they  are  hot,  as  the  contraction  of  the  heated 


DESCRIPTION   OP  INSTRUMENTS.  13 

air  inside  may  eventually  cause  water  to  enter  at  the  insu- 
lated terminals.  After  sterilizing,  a  little  sterilized  vaseline, 
or  similar  preparation,  is  rubbed  over  the  inner  faces  of 
the  jaws  of  the  forceps  to  cover  them  with  a  thin  film, 
which  will  prevent  the  tissues  from  adhering  to  the  instru- 
ment. The  iTibber-covered  end  of  the  electrical  cable  is 
sterilized  in  boiling  water  and  afterward  wrapped  in  a 
sterilized  towel  or  immersed  in  an  antiseptic  solution — such 
as  a  five-per-cent  carbolic  solution — until  needed.  Bichlo- 
ride of  mercury  should  not  be  used,  as  it  attacks  the  metal 
sleeves  at  the  end  of  the  cable. 

In  aj)plying  the  forceps,  all  the  tissues  to  be  treated 
should  be  firmly  compressed  between  the  heated  jaws  of 
the  instrument,  for  if  a  portion  extend  beyond,  a  second 
application  will  be  necessary.  Before  the  electric  current 
is  turned  on,  a  piece  of  gauze  or  a  shield  is  applied  where 
needed  between  the  forceps  and  the  adjacent  tissues  to 
protect  them  from  injury  by  contact  with  the  hot  instru- 
ment. Tissues  which  do  not  touch  the  jaws  require  no 
protection. 

The  two  connector  sleeves  at  the  end  of  the  flexible 
cable  are  then  slipped  over  the  two  terminals  on  the  end 
of  the  forcej^s  and  pushed  firmly  into  place  to  make  a 
good  electrical  connection.  If  the  electric  current  has  been 
previously  turned  on,  the  putting  of  the  connector  sleeves 
into  place  completes  the  circuit  and  establishes  the  cur- 
rent ;  but  if  this  has  not  been  done,  the  current  is  now 
turned  on. 

The  method  of  connecting  the  forceps  to  the  battery 
or  transformer,  which  may  be  used  as  a  source  of  electricity, 
is  plainly  shown  by  Figs.  6,  7,  8,  and  9,  so  that  no  expla- 
nation is  needed.  The  current  required  to  properly  heat 
the  forceps  is  noted  for  each  one  made.  Therefore,  it 
can  be  regulated  to  suit  the  forceps  from  the  indications 
of  an  amperemeter  included  in  the  circuit  to  measure  the 
strength  of  the  cun-ent.  This  is  the  best  way  ;  but  if  no 
amperemeter  be  convenient,  experiments  upon  a  piece  of 


14 


ELECTRO-H^MOSTASIS  IX   OPERATIVE   SURGERY. 


raw  meat  will  enable  one  to  regulate  tlie  current  to  suit 
tlie  forceps,  so  that  desiccation  is  obtained  in  the  proper 
time.     Experience  will  enable  the  operator  to  tell  if  the 


Forceps. 


Fig.  6. — Forceps  heated  by  the  electric  current  from  a  storage  battery. 

temperature  be  right  by  touching  the  forceps  from  time  to 
time ;  tliis  can  be  done  without  pain  as  the  lieat  is  concen- 
trated upon  the  inner  surfaces  of  the  jaws,  and  tlie  other 
parts  of  tlie  instrument  are  not  as  hot.  One  setting  of  a 
transformer  or  of  the  rheostat  of  a  storage  battery  will  be 
sufficient,  if  the  same  adjustment  be  made  in  subsequent 
operations  ;  but  the  battery  should  not  be  used  when  its 
charge  is  nearly  exhausted,  if  uniform  results  are  desired, 
unless  an  amperemeter  be  employed.  For  the  same  reason, 
the  transformer  should  be  fed  by  an  electric-light  current, 
as  this  has  an  almost  constant  pressure,  and  not  by  one 
used  exclusively  for  power,  as  such  a  current  is  subject  to 
considerable  changes  of  pressure.  An  amperemeter  should 
be  used  with  the  ordinary  primary  battery  for  the  polariza- 
tion, as  the  varying  strength  of  the  exciting  fluid  prevents 
it  from  being  adjusted  so  as  to  furnish  a  current  of  uniform 
strength. 


DESCRIPTION   OF  INSTRUMENTS. 


15 


Before  removing  tlie  forceps,  the  tissues  projecting  be- 
yond its  jaws  are  cut  oif,  whidi  may  in  some  cases  be  done 
while  the  heat  is  being  applied,  in  order  to  save  time. 
There  being  danger  of  losing  sight  of  the  stump  by  its 
dropping  back  into  the  abdominal  cavity,  as  for  example 
may  happen  in  ovariotomy,  the  tissues  on  the  under  side 
of  the  jaw^s  should  be  grasped  by  a  shield  or  compression 
forceps  to  hold  the  stump  in  place  for  inspection.  The 
electrical  forceps  is  then  carefully  opened  far  enough  to 
allow  the  desiccated  stump  to  slide  out  from  between  the 
jaws  in  the  direction  of  the  teeth.  Care  in  this  is  impor- 
tant, for  if  the  tissues  should  adhere  to  the  instrument, 
which  may  happen  if  vaseline  be  omitted,  they  might  be 
torn  apart  and  a  ragged  stump  be  left. 


Socket  dndlP/ug: 


Fig.  7. — A  transformer  connected  by  a  cable  and  plug  to  an  incandescent  lamp 
socket  on  an  alternating  electric-light  circuit,  and  heating  a  forceps  by  the 
low-pressure  current  generated  in  its  secondary. 


Before  using  the  forceps  for  the  first  time,  it  is  instruct- 
ive to  experiment  with  them  on  a  piece  of  raw  meat,  so 
as  to  become  familiar  with  their  action,  as  well  as  to  ascer- 


16 


ELECTRO-H^MOSTASIS  IN   OPERATIVE  SURGERY. 


DESCEIPTION"  OF  INSTRUMENTS. 


17 


18  ELECTRO-H^MOSTASIS   IN  OPERATIVE   SURGERY. 

tain  whether  the  source  of  electricity  is  suitable  and  can  be 
properly  controlled. 

Absence  of  bleeding  upon  the  removal  of  the  forceps 
shows  that  the  desiccation  has  been  effective,  and  the 
stump  can  be  left  without  fear  of  secondary  haemor- 
rhage. The  occurrence  of  bleeding  immediately  upon 
the  removal  of  the  forceps  indicates  that  the  desiccation 
has  been  insufficient,  or  that  some  of  the  tissues  have 
escaped  the  grasp  of  the  forceps.  In  this  event,  reap- 
ply the  forceps  to  the  stump  and  repeat  the  heating, 
giving  about  ten  per  cent  more  current,  or  continuing 
the  heat  for  a  longer  time  if  the  bleeding  has  been  due 
to  insufficient  desiccation. 

The  time  required  for  desiccation  varies  from  a  half 
to  two  minutes,  according  to  the  thickness  of  the  com- 
pressed tissues  or  size  of  the  arteries,  two  minutes  being 
required  for  the  ordinary  ovarian  pedicle  and  the  broad 
ligament.  If  desired,  or  if  the  tissues  be  very  thick,  the 
current  can  be  continued  for  three  or  four  minutes,  or  even 
longer  without  danger,  on  account  of  the  low  temperature. 
When  the  time  of  application  has  expired,  the  current  can 
be  shut  off  by  a  switch  or  by  removing  the  connector  from 
the  forceps.  The  desiccation  can  be  hastened  by  starting 
with  more  than  the  usual  current,  and  continuing  the 
greater  current  for  about  a  third  of  the  time  of  applica- 
tion. For  example,  if  the  current  necessary  to  properly 
heat  the  forceps  is  ten  amperes  and  the  time  of  applica- 
tion is  two  minutes,  give  twelve  amperes  for  about  forty 
seconds,  then  decrease  to  ten  amperes  for  the  rest  of  the 
time.  It  is  well  to  commence  with  the  forceps  closed 
on  the  first  notch  of  the  lock,  and  after  the  heat  has 
been  applied  for  about  half  a  minute  and  the  tissues 
have  begun  to  shrink  to  close  the  instrument  fully.  In 
this  way  the  greatest  possible  compression  of  tissues  is 
obtained. 

In  the  treatment  of  isolated  arteries  the  end  of  the 
vessel  is  grasped  by  a  tenaculum,  and  the  electric  artery 


DESCRIPTION  OP  INSTRUMENTS.  19 

forceps  applied  crosswise,  or  the  artery  is  seized  by  tlae 
electric  forceps  in  the  same  manner  as  with  an  ordinary 
artery  forceps  when  a  ligature  is  to  be  used.  Isolated 
arteries,  or  those  inclosed  in  a  mass  of  tissue,  when  treated 
by  this  method  are  so  thoroughly  and  completely  closed 
that  they  can  not  be  opened  up  again  either  by  blood 
pressure  or  the  most  critical  dissection.  This  has  been 
clearly  observed  and  fully  demonstrated  both  clinically  and 
by  laboratory  experiments. 

The  end  of  an  artery  or  the  stump  of  a  pedicle  when 
thus  treated  resembles  parchment  in  gross  appearance. 
The  thickness  depends  upon  the  size  of  the  vessel  or  mass 
of  tissue  treated.  A  large  uterine  artery  is  reduced  to 
about  a  line  in  thickness,  and  an  or-  r- 
dinary    broad-ligament   pedicle   to   less  j  i      , 

than  an  eig^hth  of  an  inch  in  thickness.  ,  ^ 

See  Fig.  10.      The   part  is  translucent  |      '    '   Ij     \\  \ 
and  structureless,  and  thus  enables  the  |  ^>  ,■ 

surgeon    to   tell   at  a  glance  when  the  I 
treatment  is  incomplete,  by   observing;  b;  "   „     ,       ,      ,,     ' 

^        .  ''  "    Fig.  10. — An  artery  from 

the   vessels   that   remain  unclosed ;    he     fresh  beef  closed  solidly 

,  ,  ,i,,i  nij_bv  author's  method  in 

knows  then  that  the  pressure  and  neat  half  a  minute.  Seen  in 
should  be  reapplied  to  complete  the  SoT'l ile  size"! '"^ '''' 
haemostasis. 

Occasionally  in  treating  a  thick  mass  of  tissue  the 
central  portion  of  it  becomes  heated  before  being  fully  com- 
pressed, and  the  blood  is  coagulated  in  the  vessels  and  leaves 
dark  strips  or  general  staining  of  the  tissues,  which  causes 
some  opacity  in  the  parts.  As  a  rule,  however,  the  blood 
is  pressed  out  of  the  vessels  before  the  desiccating  begins, 
and  the  stump  is  sufficiently  translucent  to  enable  the 
operator  to  see  any  vessel  that  has  escaped.  The  indica- 
tions or  requirements  for  closing  vessels  are  in  this  way 
thoroughly  fulfilled  by  the  complete  fusing  together  of  the 
walls  of  the  vessels  so  that  they  do  not,  in  fact  can  not, 
come  apart.  This  I  have  demonstrated  again  and  again. 
While  I  found  in  my  first  observations  that  the  hsemostasis 


20  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

was  immediately  complete,  I  was  suspicious  tliat  when  the 
tissue  became  softened  by  absorbing  moisture  the  vessels 
might  open  up  and  subsequent  bleeding  might  return,  but 
many  clinical  experiences  and  experiments  settled  that 
question  beyond  all  doubt. 


CHAPTEE  III 

RESULTS    OF   THIS    HEMOSTATIC    PEOCESS 

To  my  clinical  observations  I  liave  the  satisfaction  and 
pleasure  of  adding  an  experiment  made  by  Dr.  R.  L. 
Dickinson.  He  placed  a  mass  of  tissue,  one  jDart  of  whicli 
was  treated  by  this  method,  into  non-sterilized  water  and 


Fig.  11. — A,  untreated  end;   B,  desiccated  end. 

let  it  remain  immersed  for  about  seventy-two  hours.  At 
the  end  of  that  time  the  tissue  not  treated  was  a  soft  pulpy 
mass  that  broke  down  under  pressure  of  the  iingers ;  while 
the  desiccated  portion  remained  iirai,  though  somewhat 
softened  by  the  water,  but  with  no  separation  of  its  com- 
ponent parts,  neither  could  he  iind  any  part  w^here  cleavage 

21 


22  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

or  dissection  could  be  made.     I  have  repeated  this  experi- 
ment many  times  with  the  same  results. 


Fig.  12.— Section  through  A,  Fig.  11:  a,  endothelial  cells  (intima);  b,  subendo- 
thelial  layer  (intima);  c,  internal  elastic  membrane  (intima);  d,  media;  e, 
adventitia  ;  /,  lumen  of  artery. 


EiG.  13.— Section  through   B,  Fig.  11 :   a,  tunica  adventitia ;    b,  tunica  media : 
c,  tunica  intima ;   d,  line  of  closed  lumen. 


RESULTS   OF   THIS   HEMOSTATIC   PROCESS.  23 

Finally,  I  may  state  tliat  I  have  employed  this  method 
in  over  two  hundred  abdominal  operations,  and  in  many 
vaginal  hysterectomies  and  other  operations,  and  have 
never  had  secondary  haemorrhage  in  any  of  them. 

These  are  the  facts  regarding  the  method  as  an  haemo- 
static. There  still  remains  the  question  of  the  subsequent 
behaviors  of  the  ends  of  the  vessels  and  the  tissue  thus 
treated — in  other  v^ords,  the  process  of  repair. 

From  all  the  facts  that  I  could  gather  on  this  subject 
in  actual  practice,  I  concluded  that  the  desiccated  tissue 
became  first  hydrated  and  then  reorganized,  and  remained 
as  permanent  structure,  closing  for  all  time  the  ends  of  the 
blood-vessels,  lymphatics,  and  canals  so  treated.  There 
was  still  an  uncertainty  on  this  point,  until  Dr.  W.  H. 
Seymour,  the  pathologist  to  my  department  in  the  college, 
conducted  a  series  of  independent  experiments  in  the 
Hoaglancl  Laboratory.  The  account  of  these  observations 
and  experiments  by  Dr.  Seymour  and  the  illustrations 
made  under  his  supervision  are  as  follows : 

In  the  first  place,  the  doctor  observed  that  an  artery 
a  quarter  of  an  inch  in  diameter  was  reduced  to  about  a 
twelfth  of  an  inch  in  thickness  (see  Figs.  11,  12,  13),  and 
that  the  structure  of  the  tissues  was  rendered  amorphous  by 
the  heat  and  pressure.  The  lumen  of  the  artery  was  oblit- 
erated completely,  so  that  no  trace  of  its  original  structure 
could  be  found.  (See  Figs.  14,  15.)  A  piece  of  tissue,  con- 
taining arteries,  nerves,  fibrous,  muscular,  and  areolar  tissue, 
was  treated  in  the  same  way  and  presented  the  same  amor- 
phous appearance  and  complete  closure  of  the  arteries.  So 
completely  fused  together  were  the  walls  of  the  lumen  of 
the  arteries  that  no  trace  of  the  original  structure  could  be 
found,  neither  could  the  lumen  be  reopened  by  teasing  the 
microscopic  specimen. 

Observations  were  made  of  sections  of  the  Fallopian 
tubes,  appendix  vermiformis,  ureters,  and  other  canals 
lined  with  mucous  membrane,  and  the  same  amorphous  con- 
ditions were  found.      The  structure  of  the  mucous  mem- 

3 


24: 


ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 


brane  was  so  completely  changed  that  no  part  of  its  original 
structure  could  be  found  by  microscopical  examination. 


Fig.  14  (under  low  power). — 1,  desiccated  end  ;  a  a',  line  of  desiccation ;  b,  lumen 
of  artery  ;  c,  tunica  intima ;  d,  tunica  media  :  e,  tunica  adveutitia. 


Fig.  15  (under  high  power). — 1,  desiccated  end ;  2,  untreated ;  a  a',  line  of  desic- 
cation ;  b,  remains  of  lumen. 


RESULTS  OF  THIS  HEMOSTATIC  PROCESS.  25 

The  thorouglmess  of  the  closure  of  the  arteries  was 
demonstrated  by  attaching  a  fountain  syringe  to  the  opening 
of  the  artery  and  using  double  the  ordinary  blood  pressure 
without  opening  the  closed  end  of  the  vessel. 

The  advantages  that  may  be  fairly  claimed  for  this  wav 
of  controlling  bleediog  in  surgery  are,  that  it  is  certain  and 
reliable  in  closing  isolated  vessels  or  those  imbedded  in 
masses  of  tissue,  like  an  ovarian-tumor  pedicle  for  example. 
At  the  same  time  that  bleeding  is  arrested,  all  lymphatics 
are  sealed  up,  which  prevents  septic  absorption.  The 
tissues  of  the  stump  are  reduced  to  the  smallest  possible 
size,  and  there  are  no  raw  surfaces  left  to  form  adhesions 
to  the  abdominal  or  pelvic  viscera,  nor  any  foreign  sub- 
stance left  in  the  tissues  to  cause  mischief,  advantages  that 
can  hardly  be  overestimated. 

Tissues  which  have  become  friable  by  disease  and  can 
not  withstand  sufficient  pressui'e  of  a  ligature  to  control 
bleeding  are  easily  managed  by  this  method.  When  the 
tissues  that  form  the  pedicle  of  a  suppurating  ovarian  cys- 
toma or  a  pyosalpinx  contain  septic  germs,  a  condition  in 
which  the  ligature  is  most  objectionable,  a  better  and  much 
safer  stump  can  be  made  in  this  way.  A  ligature  used 
when  the  tissues  are  in  this  condition,  especially  a  catgut 
one,  is  very  objectionable,  for  the  dead  animal  tissue  of 
such  a  ligature  forms  a  perfect  medium  for  the  development 
of  disease  germs.  It  is  also  the  only  way  that  canals  lined 
with  mucous  membrane — the  Fallopian  tube  and  the  appen- 
dix veiTQiformis,  for  example — can  be  permanently  closed. 
This  will  be  referred  to  when  discussing  special  operations. 

Nerves  that  accompany  the  vessels  are  immediately  de- 
vitalized, and  hence  there  is  less  pain  and  irritation  in  the 
stump.  The  heat  employed  sterilizes  the  parts  involved, 
and  therefore  the  operation  is  perfectly  aseptic.  To  these 
many  advantages  may  be  added  that  it  leaves  the  stump 
of  a  pedicle  or  the  end  of  an  artery  in  a  condition  re- 
quiring the  least  reparatory  care,  so  that  recovery  is  more 
prompt,  uneventful,  and  complete. 


26 


ELECTRO-H^MOSTASIS  IN   OPERATIVE  SURGERY. 


Macroscojjic  and  Microscopic   Appearances  of  the  Fallopjian  Tube 
treated  icith  the  Electro-hcemostatic  Forceps. 

These  observations  have  been  made  on  two  stumps,  taken  from  canine  subjects, 
at  the  end  of  the  third  and  tenth  day  of  the  healing  process,  following  laparotomy. 

In  each  instance,  prior  to  the  application  of  the  forceps,  careful  antiseptic 
measures  were  followed  out  in  the  exposure  of  the  tube  and  uterus.     The  haemo- 


OPPOSITE 

TUBE 


STUMP 
°^    TUBE 


CEIRVIX 


Fig.  16  represents  the  tube  removed   at  the  end  of  the  third  day  of  the  healing 

process. 


static  forceps  of  the  smallest  size  was  placed  on  each  stump  for  one  minute,  and 
an  electric  current  used  of  sufficient  strength  to  raise  the  temperature  of  the  for- 
ceps to  180'. 

Macroscopic  Appearance  (Fig.  16). — The  forceps  was  placed  about  half  an  inch 
from  the  bifurcation  of  the  uterus  on  the  Fallopian  tube,  broad  ligament,  and  blood- 
vessels. At  the  point  of  application  is  noted  a  constriction  corresponding  in  width 
to  the  cautery  clamp,  on  the  surface  of  which  are  numerous  corrugations  which 
correspond  to  the  same  in  the  blades  of  the  instrument.  A  decided  compression 
is  shown  to  exist  at  the  point  of  application,  and  also  a  quantity  of  recent  lymph 


RESULTS  OF   THIS  HAEMOSTATIC  PROCESS.  27 

and  solid  exudate  found  over  the  free  end  of  the  stump.  Considerable  ecchy- 
motic  haemorrhage  is  noticed  at  the  uterine  end  of  the  area  treated  with  the  haemo- 
static forceps.  The  free  end  of  the  tube  is  seen  to  be  softened,  and  corresponds 
in  appearance  with  what  might  be  expected  in  the  earlier  stages  of  coagulation 
necrosis. 

On  an  examination  of  the  lumenal  portion,  macroscopically,  the  canal  is  seen 
to  be  obliterated. 

Microscopic  Appearance  (Plate  I,  Fig.  1,  longitudinal  section). — Under  the  low 
power  (Plate  I,  Fig.  2)  the  mucosa  and  submucosa  are  everywhere  infiltrated  with 
countless  small  round  cells ;  the  blood-vessels  are  obliterated,  their  lumena  being 
compressed.  The  free  edges  of  the  mucous  membrane  are  seen  to  be  in  apposition, 
no  distinct  line  of  demarcation  (lumenal)  being  apparent.  Considerable  softening 
exists  in  the  outer  portions  of  the  wall  of  the  oviduct.  The  small  round  cells 
can,  with  little  difficulty,  be  traced  far  back  into  the  muscular  layers  of  the  organ. 

Under  the  high  power  (Plate  I,  Fig.  3)  are  seen  countless  small  round  cells  of 
the  reparative  process,  intermingling  with  which  are  also  fine  fibrous  elements  sur- 
rounding small  and  large  areas  of  coagulation  necrosis.  On  studying  the  lumenal 
portion  of  the  mucous  membrane  the  small  round  cells  of  one  surface  seem  to 
merge  or  blend  with  those  of  the  opposite,  thus  preventing  the  recognition  of  the 
lumenal  margin  of  the  mucous  membrane. 

Macroscopic  Appearance  (Fig.  17). — The  tube  resembled,  in  its  treated  portion, 
that  of  the  third-day  specimen,  the  treated  area,  however,  being  much  duller  in 


*  -rrm 

%. 

•        iBmJVi       ''i^BIl        l^mL      -^^m        i^H           sB 

m         jSm              i                   \bSSS0^^'^'^ 

FIVE    TIMES     LIFE     SIZE. 

Fig.  17  represents  the  tube  removed  at  the  end  of  the  tenth  day  of  the  healing 

process. 

outline,  firmer  over  its  end,  and  containing  much  less  softened  material  and  lymph 
than  in  the  former  specimen.     The  lumen  can  not  be  macroscopically  identified. 

Microscopic  Appearance. — A  section  was  made  of  a  portion  of  the  oviduct 
through  tlie  lumen  and  mucosa,  longitudinally,  at  the  point  of  application  of  the 


28 


ELECTRO-HiEMOSTASIS  IN   OPERATIVE  SURGERY. 


g  a 

g  ^ 
^  ^ 


c     2 


P5 


be 


RESULTS   OF  THIS  HEMOSTATIC   PROCESS.  29 

haemostatic  forceps.  The  duller  portion  represents  marked  areas  of  coagulation 
necrosis,  together  with  some  haemorrhage  by  diapedesis,  shown  in  adjacent  neigh- 
borhoods. 

The  mucos;T3  of  the  two  walls  of  the  tube  are  seen  to  be  in  contact,  thus  produc- 
ing actual  obliteration  of  the  lumen  of  the  tube  due  to  active  jyroliferation  of  the 
cells  of  the  mucosa  and  infiltration  of  small  round  cells. 

Plate  II,  Fig.  1,  represents  one  of  the  areas  of  coagulation  necrosis  in  the  more 
superficial  portion  of  the  mucous  membrane.  Plate  II,  Fig.  2,  represents  a  smaller 
area  more  highly  magnified,  showing  countless  small  round  cells  from  infiltration 
processes. 


CHAPTER   lY 

ELECTEO-H^MOSTASIS    IJST    OVARIOTOMY 

The  part  of  this  work  relating  to  tlie  management  of 
hsemorrhage  in  abdominal  and  pelvic  surgery  is  of  necessity 
fragmentary,  as  it  treats  of  hsemostasis  in  this  class  of  ojDer- 
ations  only.  In  describing  this  method  of  arresting  the 
haemorrhage  which  occurs  when  making  the  abdominal 
section,  separating  adhesions,  and  treating  the  pedicle  in 
ovariotomy,  I  shall  follow  the  steps  of  the  operation  in  the 
order  in  which  they  have  just  been  named. 

The  Jiijemorrhage  in  ahdonmial  section  comes  mostly 
from  the  vessels  of  the  skin,  and  should  be  arrested  if  at 
all  free  before  dividing  the  deeper  stmctures.  The  vessels 
should  be  seized  with  the  artery  haemostatic  forceps  and 
heated  under  pressure  until  they  are  closed.  The  method 
of  treating  small  vessels  in  incised  wounds  is  fully  de- 
scribed under  the  head  of  extirpation  of  the  mammary 
gland,  which  will  be  described  in  a  later  chapter.  If  the  in- 
cision in  the  deeper  structures  of  the  abdominal  wall  is 
made  in  the  median  line,  as  it  should  be,  and  the  large 
veins  that  are  sometimes  found  in  the  peritoneum  are 
avoided,  no  important  haemorrhage  occurs.  The  advan- 
tages of  treating  bleeding  vessels  in  this  part  of  the  oper- 
ation are  that  no  ligatures  are  left  in  the  wound,  and  the 
injury  of  tissue  caused  by  twisting  the  arteries  or  bruising 
them  wdth  compression  forceps  is  avoided,  and  therefore 
the  tissues  are  left  in  a  better  condition  to  heal  promptly. 
It  is  my  opinion  that  this  is  a  very  important  factor 
guarding  against  subsequent  ventral  hernia. 

30 


ELECTRO-H^MOSTASIS  IX  OVARIOTOMY. 


31 


Adhesions  of  the  omentwni  to  the  cyst  wall  or  tumor  are 
treated  by  making  traction  upon  the  cyst  wall  to  bring  it 
and  the  adherent  portion  of  the  omentum  out  of  the  ab- 
dominal wound.  A  narrow-bladed  forceps  is  applied  to 
the  omentum,  close  to  the  cyst  wall,  and  the  portion  in  the 
grasp  of  the  forceps  heated  under  pressure  until  fully 
desiccated.  The  portion  thus  treated  is  divided  near  to 
the  cyst  wall  but  in  the  line  of  desiccation.  See  Fig.  18, 
which  shows  a  part  that  has  been  treated  and  divided,  and 
another  portion  in  the  grasp  of  the  forceps.  In  cases  hav- 
ing a  large  portion  of  the  omentum  surface  attached  the 
adherent  part  can   not   be   brought   out    of    a    small-sized 


Fig.  18. — The  treatment  of  omental  adhesions. 

wound  far  enough  to  reach  the  free  portion  to  be  separated. 
In  such  conditions  the  incision  should  be  enlarged  suffi- 
ciently to  facilitate  the  operator's  manipulations  partially 
Avithin  the  abdominal  ca\dty.  Great  care  is  necessary  in 
such  cases  to  protect  the  intestines  from  the  heat  while  the 
forceps  is  being  used.  Fortunately  such  adhesions  are  veiy 
rare.  The  omentum  being  thin  and  the  vessels  small,  only 
about  twenty  to  thirty  seconds  are  requii'ed  to  close  them. 
In  rare  cases,  when  the  omentum  is  thickened  by  inflam- 
mation, and  the  vessels  very  much  enlarged,  a  minute  of  the 
heat  may  be  required. 


32 


ELECTRO-H^MOSTASIS  IN   OPERATIVE  SURGERY. 


Fig.  19. — Artery  forceps. 


Adhesions  of  the  A'p'pendix  Vermiform  is. — The  appendix 
is  found  adherent  in  pyosalpinx  quite  frequently,  and  is 
discussed  in  connection  with  that  subject.  Suffice  it  to  say 
here  that   when  the   appendix  is  adherent  to  an   ovarian 

tumor  it  should  be 
removed  with  the 
tumor. 

The    method    of 
removing  the  appen- 
dix is  given  in  the  chapter  on  appendectomy. 

The  raw,  bleeding  surfaces  left  after  separation  of  ad- 
hesions to  the  wall  of  the  abdomen,  deep  down  in  the  sac 
of  Douglas  or  elsewhere,  are  treated  first  by  seizing  the 
largest  bleeding  vessels  with  the  artery  forceps  (see  Fig. 
21)  and  closing  them.  Then  the  oozing  from  the  very 
small  vessels  is  stopped  by  using  the  dome-shaped  instru- 
ment. (See  Fig.  35.)  This  is  slowly  passed  over  the  sur- 
faces until  all  oozino;  ceases. 

The  operator  must  guard  against  letting  the  intestines, 
uterus,  or  bladder  come  into  contact  with  the  dome  instru- 
ment when  it  is  in  use.  With  ordinary  care  the  needed 
protection  can  be  assured  by  having  the  patient  in  the 
Trendelenburg  position  and  keeping  the  abdominal  and 
pelvic  viscera  out  of  harm's  way  with  sponges  and  retractors, 
as  illustrated  in  Fio;.  21. 

The  technique  is  exceedingly  simple,  and^  the  results 
most  satisfactory  compared  with  the  old  way  of  ligating 
the  larger  vessels  (always  a  most  difficult  thing  to  do)  and 
using  persulphate  of  iron  or  hot  water  to  stop  the  oozing. 


Fig.  20.— The  dome. 


In  fact  I  never  was  able  to  arrest  bleeding  and  oozing  com- 
pletely and  quickly,  and  make  the  parts  clean  and  dry  in 
pelvic  surgery  of  this  kind  until  I  devised  this  method  of 
operating. 


ELECTRO-H^MOSTASIS  IN   OVARIOTOMY. 


33 


Intestinal  adliesions  are  managed  by  makiug  gentle 
traction  and  stretching  the  adhesion  so  that  the  forceps 
can  be  placed  between  the  cyst  wall  and  the  intestines. 
"While  the  pressure  and  heat  are  being  applied,  the  shield 
forceps  should  be  placed  on  the  side  toward  the  intestines 
to  protect  them.  When  this  is  impossible,  owing  to  close 
and   extensive  adhesions,  the   intestine  is  dissected  away 


Fig.  21. — Protecting  the  uterus  from  the  forceps. 

from  the  cyst  in  such  a  manner  as  to  leave  a  portion  of  the 
external  coat  of  the  cyst  wall  on  the  side  of  the  intestine. 
These  flaps  are  brought  together  over  the  raw  surface  of 
the  intestine  and  seized  with  the  forceps,  compressed  and 
desiccated.     (See  Fig.  22.) 

In  doing  this  the  shield  forceps  should  be  used  to  keep 
the    heat   from  reaching  the   intestine.      This  instrument 


34  ELECTRO-HiEMOSTASIS  IN  OPERATIVE   SURGERY. 

resembles  an  ordinary  compression  forceps,  but  has  thin^ 
flat  shields  instead  of  jaws,  as  shown  by  Fig.  23.  The 
shields  are  constructed  of  thin  blades  of  steel  coated  with 
a  substance  which  is  a  poor  conductor  of  heat,  such  as 
hard  rubber,  and  are  longer  and  broader  than  the  jaws  of 
the  electrical  forceps.  One  side  of  each  shield  is  flat  and 
the  other  is  beveled,  as  shown,  so  that  the  inside  edges  are 
chisel  shaped.  The  flat  sides  are  placed  uppermost,  close 
against  the  electrical  instrument.  When  properly  placed, 
the  shield  forceps  is  locked  with  sufficient  pressure  to  re- 


FiG.  22. — The  treatment  of  intestinal  adhesions. 

tain  the  desiccated  stump  for  inspection  after  the  other 
instrument  is  removed. 

Adhesions  to  the  rectum  (the  most  difficult  of  all  to 
manage)  are  treated  in  the  same  way  as  intestinal  adhesions, 
with  this  difference,  that  when  the  adhesions  are  very 
strong,  and  the  cyst  wall  changed  in  structure  by  inflam- 
mation, a  part  of  the  cyst  wall  should  be  left  attached  and 
its  lining  membrane  destroyed  with  the  dome  cautery. 

Adhesions  of  the  bladder  to  the  tumor  are  treated  by 
dissecting  off  the  bladder  and  then  closing  the  peritoneum 


ELECTRO-H^MOSTASIS  IN   OVARIOTOMY. 


35 


over  the  bladder  witli  fine  catgut  sutures 


Adliesions  that 
are  recent,  not  very  extensive,  and  easily  separated,  are 
treated  by  touching  the  raw  surface  with  the  dome  cauteiy 


at  a  temperature  of  180°,  to  arrest  any  oozing  that  may 
take  place. 

The  Pedicle.— T\iQ  cyst  sac  or  tumor  being  withdrawn 
from  the  abdominal  cavity  the  pedicle  is  examined  with 
regard  to  its  length  and  thickness,  to  determine  the  point 
at  which  it  should  be  divided,  and  the  size  of  forceps  or 
clamp  required  for  its  treatment.  Small  and  medium-sized 
pedicles  call  for  the  smallest  pedicle  forceps,  illustrated  by 
Fig.  24,  and  constructed  as  follows :  The  instrument  is 
jointed  at  the  distal  end  by  a  detachable  lock,  and  has  a 
projection  on  either  blade  at  the  proximal  end  of  the  jaws, 
which  prevents  the  tissues  fi'om  spreading  when  the  foi'ceps 


is  closed.  The  handles  lock  with  the  usual  catch  near  the 
proximal  end.  Larger  pedicles  require  the  clamp  forceps, 
illustrated  by  Fig.  25,  and   constructed  in  the  same  man- 


36 


ELECTRO-H^MOSTASIS  IN   OPERATIVE  SURGERY. 


ner  as  the  small  pedicle  forceps,  but  having  a  movable 
section  which  can  be  closed  by  a  screw  attachment.  By 
this  means  the  pressure  is  made  parallel  to  the  heated  jaw, 
and  a  greater  and  more  equal  compression  is  thereby  ob- 


FiG.  25. — Clamp  forceps  for  larger  pedicles. 


tained.  The  forceps  selected  is  applied  at  the  point  where 
the  pedicle  is  to  be  divided.  One  or  two  fixation  forceps 
are  applied  to  the  base  of  the  tumor,  and  the  pedicle 
divided  between  them  and  the  haemostatic  clamp,  leaving 
a  portion  of  the  pedicle  projecting  above  the  blades  of  the 
clamp  to  prevent  slipping.  This  portion  should  be  cut  off 
close  to  the  forceps  just  before  removing  it.  The  shield 
forceps  is  applied  beneath  the  haemostatic  forceps  to  pro- 
tect the  abdominal  wall  from  the  heat,  and  to  keep  the 
stump  from  falling  back  into  the  pelvic  cavity  when  the 
haemostatic  forceps  is  removed.  (See  Fig.  26.)  This 
enables  the  operator  to  inspect  the  stump  and  see  if  it  has 
been  properly  treated  before  it  is  dropped.  If  any  portion 
of  the  stump,  or  the  whole  of  it,  indeed,  is  not  fully 
desiccated,  the  forceps  can  be  reapplied  and  the  treatment 
completed. 

Sterilized  vaseline  should  be  applied  to  the  inner  surface 
of  the  blades  of  the  forceps,  to  prevent  the  stump  from 
adhering  and  to  permit  the  forceps  to  come  off  easily.  The 
forceps  should  be  closed  only  to  the  first  notch  in  the  catch, 
and  when  the  current  has  been  turned  on  and  used  for  about 
half  a  minute  the  compression  should  be  completed  by  clos- 
ing the  forceps  to  the  last  notch.  During  the  time  that  the 
electric  current  is  being  used  the  operator  should  examine 


ELECTRO-H^MOSTASIS  IN  OVARIOTOMY. 


m 


tlie  other  ovary  and  tlie  otlier  pelvic  organs  to  see  if  any- 
thing more  in  the  way  of  operating  is  required. 

An  unusually  short,  thick,  broad  pedicle,  that  can  not 
be  accommodated  in  the  largest  clamp  forceps,  should  be 
treated  in  three  sections.  The  outer  border,  which  con- 
tains the  ovarian  vessels,  should  be  grasped  wdth  the  for- 
ceps used  for  vaginal  hysterectomy,  treated  in  the  usual 
way,  and  divided;  the  inner  border  should  be  treated  in 
the  same  way ;  the  middle  portion,  or  third  section  of  the 
pedicle,  if  not  vascular  may  be  cut  oif  without  treatment, 


Fig.  26. — Treatment  of  pedicle  of  ovarian  cyst.     (Diagrammatic.) 

and  the  edges  of  the  peritoneum  of  the  stump  closed  with 
fine  sutures.  If  the  middle  part  is  vascular  it  should  be 
caught  in  the  pedicle  clamp  and  treated  like  the  other 
sections. 


38  ELBCTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

For  one  wlio  is  not  familiar  mth  this  treatment  of  the 
pedicle  it  is  difficult  to  tell  when  the  treatment  is  sufficient 
to  be  reliable.  This  was  to  me  a  most  difficult  question 
in  my  first  operations,  but  I  soon  learned  that  if  there  was 
no  disposition  to  bleeding  when  the  clamp  was  removed,  it 
could  surely  be  trusted. 


CHAPTER  V 

ELECTEO-HiEMOSTASIS    IN   MYOMECTOMY    AND    ABDOMHSTAL 
HYSTEEECTOMY 


I  DID  a  number  of  successful  myomectomies  in  pedun- 
culated iibroids,  and  in  all  I  found  difficulty  in  control- 
ling the  bleeding  with  the  ligature.  Such  was  my  ex- 
perience that  I  never  dared  to  remove  a  sessile  subperi- 
toneal fibroid  until  I  obtained  the  haemostatic  forceps. 
Since  then  I  have  succeeded  equally  well  with  all  forms 


Fig.  27. — Treatment  of  pedicle  of  a  fibroid.  The  cnff  of  peritoneum  and  the  cap- 
sule gathered  together,  drawn  outward,  and  seized  by  electro-haemostatic 
forceps. 

of  subperitoneal  fibroids.  The  method  of  operating  when 
the  pedicle  is  long  enough  is  to  apply  the  forceps  in  the 
same  way  as  it  is  used  upon  the  pedicle  of  an  ovarian 
tumor,  compress  and  desiccate  it,  and  then  cut  away  the 
tumor. 

4  39 


40 


ELECTRO-H^MOSTASIS   IX   OPERATIVE   SURGERY. 


When  the  pedicle  is  short  and  the  fibroid  is  in  contact 
■with  and  yet  movable  upon  the  middle  coat  of  the  uterine 
wall,  the  capsule  is  divided  all  around  on  the  tumor  one  to 
two  inches  from  the  uterus.     It  is  then  dissected  off  with 


^<j^j&^ 


Fig.  28. — Line  of  incision  preparatory  to  enucleation  of  sessile  fibroid. 

the  dry  dissector  until  the  tumor  is  enucleated ;  the  empty 
portion  of  the  capsule  is  finally  gathered  together  and 
grasped  in  the  forceps  and  desiccated  by  the  electric  heat. 
(See  Fig.  27.) 

The  shield  forceps  is  used  to  protect  the  uterus  fi'om 
the  heat.  The  redundant  part  of  the  stump  which  pro- 
jects beyond  the  blades  of  the  forceps  should  be  cut  clean- 
ly off  after  the  treatment  is  completed,  and  before  the  for- 
ceps is  removed. 

Sessile  fibromata  are  treated  in  the  same  way,  excepting 


Fig.  29. — Sessile  fibroid  enucleated.     Showing  cuff  of  peritoneum. 

that  when  the  attachment  of  the  tumor  to  the  uterus  is 
quite  broad  the  incision  of  the  capsule  should  be  made 
higher  up  on  the  tumor — that  is  to  say,  it  should  be  nearly 
as  high  as  the  diameter  of  the  base  of  the  tumor  (Fig.  28). 


MYOMECTOMY  AND  ABDOMINAL  HYSTERECTOMY. 


41 


When  tlie  incision  is  made,  and  enougli  of  the  capsnle  has 
been  freed  from  the  tumor  to  get  hold  of,  ordinary  com- 
pression forceps  should  be  used  to  control  bleeding  until 
the  enucleation  is  completed  (Fig.  29).  The  two  sides  of 
the  capsule  should  be  held  apart  while  the  surface  of  the 
uterus  from  which  the  tumor  was  detached  is  carefully  in- 


Fig.  30.— The  use  of  the  dome  in  treating  bleeding  raw  surface  after  enucleation 

of  sessile  fibroid. 


spected,  and  all  oozing  stopped  by  the  application  of  the 
dome  cautery  mentioned  in  the  description  of  ovariotomy 
(Fig.  30).  The  flaps  of  the  capsule  should  be  brought 
together,  grasped  by  the  forceps,  compressed  and  desiccated 
(Fig.  31).     This  completely  arrests  all  haemorrhage,  and 


42  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

leaves  the  smallest  possible  stump.  Occasionally  several 
small  subperitoneal  fibroids  accompany  one  or  more  large 
ones.  These  little  ones  are  quickly  disposed  of  by  making 
an  incision  through  the  capsule  at  the  summit  of  the  tumor 


FAV  SURFACE  \    ^H I  OTl  eM-"^' 


Fig.  31. — Steps  in  treating  stump  after  enucleation  of  sessile  fibroid. 

with  the  cautery  knife,  and  enucleating  and  treating  the 
sac  or  capsule  as  already  described. 

ABDOMINAL    HYSTERECTOMY    FOR    FIBROMATA 

The  abdominal  incision  is  made  long  enough  to  permit 
lifting  both  the  uterus  and  the  tumor  out  of  the  abdominal 
cavity.  The  body  of  the  uterus  is  drawn  toward  the 
left  side,  and  the  right  side  of  the  abdominal  wall  is  re- 
tracted, so  that  the  right  broad  ligament  is  fully  exposed. 
A  compression  forceps  is  applied  to  the  upper  part  of  tlie 
broad  ligament,  including  the  ovarian  arteiy,  near  the  brim 
of  the  pelvis.  Another  forceps  is  applied  opposite  the 
fost  one,  near  the  uterus.  The  round  ligament  is  caught 
in  a  forceps  in  the  same  way  and  the  ligament  divided 
down  to  near  the  uterine  artery.  The  lower  part  of  the 
ligament  is  opened  up  and  the  uterine  artery  found  and 
caught  in  a  compression  forceps.  If  the  artery  can  not  be 
separated  from  the  tissues  of  the  ligament  mthout  much 
trouble,  the  ligament  and  artery  may  be  seized  e7i  m.asse. 
The  uterus  is  separated  from  the  bladder,  and  the  cervix 
uteri  divided  or  amputated  in  the  usual  way.  The  uterus 
is  tilted  still  farther  to  the  left  side  to  bring  up  the 
lower  portion  of  the  broad  ligament  and  left  uterine  ar- 
tery.    This  also  is  seized  by  compression  forceps  and  the 


MYOMECTOMY  AND  ABDOMINAL   HYSTERECTOMY. 


.43 


ligament  divided  fi"om  below  upward.  Forceps  are  applied 
to  the  round  ligament  and  the  ovarian  artery  when  they 
are  approached  in  the  process  of  dividing  the  ligament.  Fig. 
32  shows  the  line  of  incision,  and  Fig.  33  shows  the  exsec- 
tion  of  the  uterus  and  the  temporary  control  of  the  arteries 
with  compression  forceps. 

The  tumor  having  been  thus  removed,  the  treatment  of 
the  vessels  is  accomplished  as  follows  :  The  divided  end 
of  the  artery  is  caught  up  \\'ith  a  line  dissecting  forceps  and 
drawn  out  of  the  tissues  of  the  lio-ament  and  seized  with 

o 

the  haemostatic  forceps,  compressed  and  desiccated.  When 
it  happens  that  the  broad  ligament  has  been  divided  close 
up  to  the  compression  forceps,  the  artery  can  not  be  iso- 


A  A,  Cla7nps     ^^SH 
on  ovarian       ,^^^SH 
artery.              ^jW^ 

■^ 

B   B,   Clamps   on  _.-' 
artery  of  round' 
ligament. 

C   C,    Clamps-  on  ...- 
uterine  artery. 

<-— -  ^v 

Fig.  32. — Treatment  of  right  broad  ligament  and  temporary  control  of  vessels. 


lated  sufficiently  without  taking  off  the  forceps ;  but  if  the 
end  of  the  artery  is  grasped  with  the  dissecting  forceps  the 
tissues  can  be  stripped  back  from  the  artery  far  enough  to 
admit  the  grasp  of  the  haemostatic  forceps.     Fig.  34  shows 


44 


ELECTRO-H^MOSTASIS  IX  OPERATIVE   SURGERY. 


the  ovarian  artery  after  it  has  been  closed,  and  also  the 
uterine  artery  in  process  of  being  closed  or  treated. 

I  was  fearful  that  the  pressure  of  the  forceps  upon  the 
broad  ligament  if  continued  for  any  great  length  of  time 


Temporary  clamps  on  divided 
vessels  of  right  broad  liga- 
ment. 


1  F'  '  '•i      ^^  <?:  1   Temporary  clamp 
^  on  ovarian  ar- 

teiy 
Temporary  clamp 
^r  on    round-liga- 

ment artery. 
Temporary  clamp 

—ry-r on  left  uterine 

-  •■/  artery. 


Fig.  33. — Treatment  of  left  broad  ligament  and  temporary  control  of  vessels. 

might  so  bruise  the  tissues  that  sloughing  would  take  place, 
and  the  process  of  repair  be  thereby  retarded.  So  I  treated 
each  artery  as  it  was  divided — that  is,  the  compression  for- 
ceps was  applied  lightly,  and  the  artery  and  ligament  di- 
vided and  immediately  closed  wdth  the  haemostatic  foi'ceps. 
I'hen  the  other  arteries  were  treated  in  the  same  way.  Ex- 
perience, however,  indicates  that  unless  the  compression  of 
the  tissues  is  greater  than  necessary,  the  damage  done  is 


MYOMECTOMY  AND   ABDOMINAL   HYSTERECTOMY. 


45 


not  sufficient  to  retard  repair ;  the  circulation  is  re-estab- 
lisliecl,  and  healing  goes  on  rapidly. 

The  peritoneum  is  closed  over  the  broad  ligaments  and 
stump  of  the  cervix  uteri  with  running  catgut  sutures. 
Beginning  above  on  the  left,  one  suture  is  introduced  along 
to  the  center  of  the  cervix,  the  other  suture  is  applied  from 
above  downward  on  the  right  side  until  it  meets  the  suture 
of  the  left  side,  and  the  two  are  secured  by  tying  their  ends 
together. 


Forceps  in  the  act 
of  being  re- 
moved from 
round-ligament 
artery. 

Bight  ovarian  ar- 
tery after  treat- 
ment  and  per- 
manent closure. 


Dissecting  for- 
ceps draicing 
artery  out. 


'tv. 


Temporary  con- 
trol of  vessels 
of  left  broad 
ligament  by 
clamp. 


Fig.  34. — Final  treatment  of  vessels. 


When  it  is  necessary  to  remove  the  entire  uterus,  the 
exsection  of  the  cervix  is  added  to  the  operation  above 
described.  There  are  two  w^ays  of  doing  this :  circumcising 
the  vagina  from  below,  or  opening  and  detaching  it  from 
above.  Certain  advantages  belong  to  both  ways  of  operat- 
ing in  certain  conditions ;  therefore  the  surgeon  should 
select  the  method  adapted  to  the  conditions  in  cases  as 
they  come. 


46  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

When  the  cervix  is  vdthin  reach  from  the  vagina,  it  is 
easier  to  cii'cumcise  the  cervix  uteri  through  the  vagina, 
and  the  lower  portion  of  the  bladder  can  be  more  easily 
and  safely  separated  fr'om  the  uteinis  in  this  way  than 
throuo'h  the  pelvic  cavity  from  above.  The  disadvantages 
of  this  method  are,  that  it  increases  the  time  of  operating, 
especially  when  the  vaginal  wall  is  vascular,  since  time  is 
required  to  stop  the  bleeding  before  opening  the  abdomen. 
But  when  the  cervix  uteri  is  drawn  up  out  of,  or  crowded 
to  one  side  of,  the  pelvis,  it  is  better  to  separate  the  cervix 
and  vaginal  wall  from  above. 

The  method  of  operating  which  I  have  adopted  saves 
time  enough  to  make  it  preferable,  in  my  judgment,  in  suit- 
able cases. 

Two  incisions  in  the  vaginal  wall,  one  in  front  and  one 
behind  the  cervix,  are  made,  so  that  they  meet  on  either 
side  of  the  cervix  ;  the  bladder  is  separated  from  the  uterus 
up  to  the  peritoneum,  the  vagina  is  separated  fr^om  the  pos- 
terior wall  of  the  cervix,  but  the  peritoneum  is  not  opened. 
By  this  procedure  the  lower  portions  of  the  broad  ligaments 
are  exposed.  The  haemostatic  forceps  used  in  vaginal  hys- 
terectomy is  applied  to  the  lower  portion  of  one  ligament, 
which  is  compressed  and  desiccated,  and  cut  off  from  the 
supravaginal  portion  of  the  cervix.  The  other  side  is 
treated  in  the  same  way.  This  frees  the  cervix  from  all  of 
its  attachments,  except  the  peritoneum,  and  at  the  same 
time  arrests  all  bleeding  from  the  vessels  which  supply  the 
vagina.  This  part  of  the  operation  is  performed  precisely 
as  the  first  steps  in  vaginal  hysterectomy.  The  abdominal 
part  of  the  operation  is  performed  as  already  described, 
except  that  in  place  of  amputating  at  the  cervix,  the  peri- 
toneum in  front  and  behind  the  cervix  uteri  is  opened 
toward  the  incision  made  from  the  vagina. 

It  is  sometimes  found  that  when  the  uterine  artery  is 
ligated  and  the  ligament  divided  down  to  the  part  sepa- 
rated from  the  vagina  there  is  a  branch  of  the  uterine  or 
vaginal  artery  that  bleeds ;  this  is  easily  controlled  by  using 


MYOMECTOMY  AND  ABDOMINAL  HYSTERECTOMY. 


47 


the  haemostatic  forceps.  The  dome  is  very  useful  in  arrest- 
ing capillary  oozing  in  the  deep  locations  hardly  accessible 
by  other  means.  (See  Fig.  35.)  The  peritoneum  is  closed 
over  the  broad  ligaments  in  the  way  already  described,  and 
the  vagina  is  closed  by  interrupted  suture,  including  the 
peritoneum  and  vaginal  walls. 

The  reader  will  observe  that  I  have  adopted  Kelly's 
method  of  doing  this  operation,  only  slightly  modifying  it 


Fig.  35. — The  use  of  the  dome  deep  in  the  cul-de-sac  to  arrest  persistent  oozing. 
The  patient  is  in  the  Trendelenburg  posture.  The  uterus  has  been  removed. 
The  treated  stumps  of  the  vessels  are  shown:  B,  ovarian  stump;  C,  stump  of 
artery  of  round  ligament;  U,  compressed  and  heated  stump  of  uterine  artery; 
A,  posterior,  and  I),  anterior  peritoneal  iiap. 

to  suit  the  new  method  of  controlling  the  bleeding  vessels. 
Dr.  Kelly,  in  describing  his  method  of  doing  abdominal 
hysterectomy,  adds  some  valuable  remarks  regarding  its 
advantages  in  complications,  which  I  quote  here : 

"  I  have  insisted  particularly  upon  the  novel  way  in 
which  serious  complications  are  simplified  by  this  plan  of 
treatment,  and  I  would  refer  chiefly  to  two  kinds  of  com- 
plications : 


48  ELECTRO-HiEMOSTASIS  IX  OPERATIVE  SURGERY. 

"  First,  fibroid  tumors  located  under  the  peritoneum  ol 
tlie  pelvic  floor ;  and, 

"  Second,  inflammatory  masses  situated  behind  the  broad 
ligaments,  with  dense  adhesions  to  the  pelvic  peritoneum,  to 
the  rectum,  and  often  to  the  small  intestines. 

"  In  the  case  of  the  subperitoneal  pelvic  fibroids,  it  is 
astonishing  how  difficult  they  are  to  get  at  from  above,  and 
how  easily,  on  the  other  hand,  they  roll  out  when  handled 
from  beneath  by  this  procedure. 

"  I  would  say  the  same  of  the  inflammatory  cases. 
Matted  masses,  adherent  in  all  dii'ections,  which  resist 
enucleation  from  above,  are  often  removed  with,  ease  when 
rolled  up  from  the  pelvic  floor  fi'om  below.  The  adherent 
stiTictures  seem  to  be  unrolled  in  a  natural  and  easy  way, 
in  surprising  contrast  to  the  difficulties  experienced  and  the 
injuries  inflicted  in  gaining  the  slightest  fingerhold  in  pro- 
ceedino;  from  above. 

"  To  recapitulate :  Abdominal  hysterectomy  by  the  con- 
tinuous incision  do^vn  through  one  broad  ligament,  across 
the  cervix  and  up  through  the  other  broad  ligament,  is  con- 
trasted with  hysterectomy  by  an  incision  down  to  the  cer- 
vix through  one  broad  ligament,  and  then  down  through 
the  other,  followed  by  amputation  of  the  cervix. 

"  The  special  advantages  offered  by  this  method  of 
operating  are : 

"  1.  The  saving  of  from  sixty  to  eighty  per  cent  of  time 
in  the  enucleating  stage  of  operation. 

"  2.  The  ease  with  which  intraligamentary  myomata 
and  myomata  beneath  the  pelvic  peritoneum  may  be  enu- 
cleated. 

"  3.  The  ease  with  which  inflammatory  masses  pos- 
terior to  the  broad  ligament  may  be  enucleated  by  attack- 
ing them  fi'om  below  after  dividing  the  cervix. 

"  4.  The  control  of  a  displaced  ureter  on  the  side  last 
opened  up,  keeping  it  out  of  the  way  of  injury  by  the  sim- 
ple mechanism  of  the  operation." 


CHAPTEK   YI 

ELECTRO-H^MOSTASIS    EN^    OVAEIO-SALPINGECTOMY 

Although  the  mortality  in  operations  for  pyosalpinx 
and  kindred  diseases  of  the  tubes  and  ovaries  has  been 
reduced  to  a  minimum,  there  has  been  such  a  large  per- 
centage of  incomplete  I'ecoveries  that  some  of  the  best- 
known  surgeons  have  expressed  dissatisfaction  with  the 
ultimate  results.  During  my  investigation  of  this  class  of 
uncured  cases,  I  found  that  ligation  of  the  pedicle  had  been 
l^racticed  in  all  of  them,  and  that  all  kinds  of  ligatures 
had  been  used,  while  in  those  treated  with  the  cautery 
clamp,  according  to  Keith's  method,  no  sucli  results  fol- 
lowed. Those  who  recovered  after  that  treatment  were 
permanently  relieved.  I  naturally  inferred  from  this  that 
the  ligation  was  the  cause  of  the  unfortunate  effects,  and 
in  one  sense  that  is  the  case.  In  explanation  I  must  say 
that  while  the  ligature  itself  is  the  cause  of  some  trouble, 
the  worst  afflictions  come  from  patenc}^  of  the  Fallopian 
tubes,  which  remains  after  treatment  by  ligation. 

Professor  Emil  Ries,  of  Chicago,  has  given  (see  Ameri- 
can Gynaecological  and  Obstetric  Journal,  January,  1898) 
the  unfavorable  results  following  the  removal  of  the  tubes 
and  ovaries,  and  the  causes  thereof,  in  a  most  interesting 
and  valuable  essay,  from  which  I  have  taken  the  following. 
After  noticing  that  Schauta  and  Chrobak  report  but  little 
more  than  fifty  per  cent  of  their  laparotomy  j^atients  as 
really  cured.  Dr.  Ries  suggested  that  one  of  the  most  im- 
portant causes  of  these  unsatisfactory  results  was  to  be 
found  in  the  formation  of  stump  exudates,  and  offers  a  new 

49 


50  ELECTRO-H.EMOSTASIS  IX   OPERATIVE   SURGERY. 

explanation  of  this  cause  in  the  following  observation  of 
several  cases  in  which  microscopical  examinations  were 
made  of  the  uteri  removed  some  time  after  salpingectomy. 

"  Stump  exudates  were  found  by  Schauta  in  twenty- 
eight  cases  out  of  his  one  hundred  and  seventy-two  sal- 
pingo-oophorectomies.  They  have  been  found  even  more 
frequently  by  other  observers,  and  in  my  own  experience  I 
have  repeatedly  found  them  to  be  at  the  bottom  of  trouble- 
some symptoms  months  after  the  operation.  They  produce 
pain,  sometimes  so  severe  that  the  patient  is  unable  to 
attend  to  her  work ;  in  some  cases  the  pain  is  even  worse 
than  it  was  before  the  operation.  The  exudates  are  found 
around  the  stumps  of  the  removed  tubes,  and  vary  in  size 
from  a  barely  palpable  thickening  of  the  uterine  horn  to 
the  size  of  a  hen's  egg  or  larger. 

"As  an  explanation  of  the  formation  of  these  tumors, 
Schauta  offered  the  following  two  possibilities  : 

''1.  The  inflammatory  process  creeps  on  through  the 
uterine  wall  into  the  surrounding  parametric  and  perimetiic 
tissue ;  and, 

"  2.  Germs  were  present  in  the  broad  ligament  at  the 
time  of  the  operation  (though  no  actual  observations  could 
be  offered  as  evidence  of  this),  the  connective  tissue  of  the 
broad  ligament  was  laid  bare  by  the  oj)eration,  and  in  this 
way  the  germs  could  invade  the  peritoneum. 

"Though  these  observations  did  not  meet  with  any 
opposition,  it  can  not  be  overlooked  that  we  have  no  obser- 
vations bearing  out  the  con-ectness  of  these  hyj)otheses. 
Besides,  I  can  not  help  feeling  that  they  are  very  artificial. 

"  The  cases  are  as  follows : 

"Case  I. — Mrs.  J.,  twenty -four  years  old.  Seven 
months  previously  a  left  pus  tube  and  ovary  had  been 
removed.  A  sinus  remained  which  would  not  close.  Be- 
sides, the  j^atient  has  an  ovarian  abscess  the  size  of  a  fist, 
and  hydrosalpinx  on  the  right  side.  Uterus  adherent  all 
over,  forming  part  of  the  wall  of  the  sinus.  I  operated 
September  28,   1896.      Laparotomy.     Removal  of  ovarian 


ELECTRO-H^MOSTASIS  IX  OVARIO-SALPIXGECTOMY.  51 

abscess,  hydrosalpinx,  uterus  ;  excision  of  sinus,  which  leads 
toward  the  right  cristuni  ilii  and  terminates  in  an  abscess 
which  contains  iive  silk  ligatures.     Kecovery. 

"  The  stump  of  the  tube  which  had  been  removed  seven 
months  j)i'eviously  is  excised,  and  examined  in  a  series  of 
sections,  embracing  the  entii'e  stimap  up  to  the  interstitial 
portion  of  the  tube.  The  cavity  is  open  throiigliout.  The 
epithelium  is  the  usual  low  columnar  epithelium  of  this 
portion  of  the  tube,  and  stops  at  the  surface  of  the  stump 
without  investing  the  cut  surface  of  the  stump.  No  threads 
to  be  found  in  the  stump. 

"Case  II. — Miss  W.,  twenty-five  years  old.  Several 
years  ago  removal  of  both  tubes  and  right  ovary.  Now 
chronic  pelviperitonitis  and  adherent  retroflexion.  OjDera- 
tion  by  Dr.  AY.  H.  Rumpf,  on  December  8,  1896.  Vaginal 
hysterectomy. 

"  Both  tubal  stumps  are  examined  in  series.  They  are 
perfectly  permeable,  though  the  cavity  is  very  narrow. 
Epithelium  well  preserved  up  to  the  abdominal  opening  of 
the  stump.  Besides,  the  left  tube  contains  some  epithelial 
ducts  outside  the  circular  muscular  layer  of  the  tube,  one 
of  which  enters  the  circular  muscular  layer  itself,  but  does 
not  show  any  communication  with  the  tubal  cavity  (remnant 
of  the  Wolffian  body).  No  threads  to  be  found  in  the 
stump." 

At  a  meeting  of  the  American  Gynaecological  Society, 
held  in  Boston,  June  26,  1898,  Dr.  J.  Wesley  Bovee,  of 
Washington,  D.  C,  read  a  paper  on  Patency  of  the  Stump 
after  Salpingectomy,  in  which  he  said  that  he  had  taken 
a  special  interest  in  this  subject  since  1892,  and  had  found 
in  five  specimens  from  cases  of  salpingectomy  that  the 
stumps  were  still  pervious.  So  far  as  he  knew,  only  three 
well-authenticated  cases  had  previously  been  reported. 
As  I  remember  the  reading  of  the  doctor's  paper,  he  ac- 
counted for  the  patency  by  saying  that  the  ligatures  might 
become  infected  and  slip  in  course  of  time,  or  "  mass  " 
ligatures  might  slip  off  after  closure  of  the  abdomen.     He 


52  ELECTRO-HiEMOSTASIS  IX  OPERATIVE  SURGERY. 

suggested  that  these  stuuips  might  be  successfully  occluded 
by  cutting  out  the  Fallopian  tube  by  a  wedge-shaped  in- 
cision into  the  uterine  wall  at  the  tubo-uterine  junction, 
and  closino;  the  wound  with  sutures.  Care  must  be  taken, 
he  said,  in  the  ligation  of  the  uterine  artery  in  this  situa- 
tion, aud  also  not  to  pass  the  sutures  through  the  mu- 
cosa. 

It  appears  that  Dr.  Bovee  was  not  acquainted  with  the 
work  of  others  when  his  paper  was  prepared,  but  he  de- 
serves credit  for  suggesting  a  way  of  overcoming  the  paten- 
cy of  the  tube  which  so  often  follows  the  use  of  the  liga- 
tui'e,  and  for  adding  five  more  to  the  list  of  unsuccessful 
cases  following  the  usual  method  of  operating.  This 
method  suggested  by  Dr.  Bovee  may  be  an  improvement 
upon  the  old  way  of  operating.  Still,  it  requires  longer 
time  to  introduce  sutui-es  than  to  use  a  ligatui-e,  and  if  the 
end  of  the  tube  is  septic  the  wound  in  the  uterus  is  sm-e  to 
become  contaminated  and  so  complicate  the  process  of  re- 
pair that  trouble  may  follow.  At  any  rate  I  am  quite  con- 
fident that  better  results  are  obtained  more  easily  by  the 
method  which  I  have  adopted. 

The  operation  for  the  removal  of  the  tubes  and  ovaries 
should  be  adapted  to  the  pathological  conditions  presented 
in  given  cases,  simple  and  comp)licated. 

The  incision  into  the  abdominal  wall  should  be  short, 
just  sufiicient  to  admit  two  fingers.  Extra  care  is  necessary 
to  avoid  wounding  the  omentum  or  bowels.  If  there  are 
adhesions  of  the  intestines  to  the  abdominal  wall,  the  in- 
cision should  be  enlarged  in  order  to  find  a  part  where  the 
peritoneum  can  be  safely  opened,  and  from  which  the  adhe- 
sions can  be  treated.  This  is  easier  than  to  separate  the  in- 
testines from  the  peritoneum  in  the  incision.  This  complica- 
tion is,  fortunately,  seldom  met.  I  have  occasionally  found 
the  omentum  adherent  to  the  tube  and  ovary,  and  some- 
times to  the  abdominal  wall  near  the  median  line  ;  but  it  is 
generally  free  on  one  or  both  sides,  so  that  the  tubes  and 
ovaries  can  be  reached  by  passing  the  fingers  outward  be- 


ELECTEO-H^MOSTASIS  IN  OVARIO-SALPINaECTOMY.  5a 

yond  the  adhesions  on  the  side,  and  then  drawing  and 
pushing  the  omentum  out  of  the  way.  When  no  free  part 
can  be  found,  the  omentum  should  be  picked  up  and 
divided  in  or  near  the  median  line,  and  the  bleeding  ves- 
sels closed  with  the  haemostatic  forceps.  Two  fingers 
should  be  passed  into  the  wound  and  the  fundus  uteri 
found.  This  is  a  guide  to  the  tubes.  Adhesions,  when 
they  are  not  too  old  and  strong,  should  be  separated  with 
the  fingers,  but  care  must  be  exercised  not  to  rupture  the 
tube.  When  both  tube  and  ovary  are  freed  from  adhesions, 
they  should  be  hooked  up  with  the  fingers  and  brought  out 
through  the  wound,  or  up  into  it.  By  traction  in  this  way 
a  pedicle  is  formed,  included,  and  held  between  the  fingers 
until  the  haemostatic  forceps  is  applied,  the  shield  forceps 
adjusted,  and  the  pedicle  treated  in  the  way  described 
under  the  head  of  Ovariotomy  for  Ovarian  Cystomata. 
(See  page  37.) 

One  sometimes  finds  the  pedicle  too  short  to  permit  the 
tube  and  ovary  to  be  drawn  out  of  the  wound  far  enough 
to  apply  the  forceps  outside  of  the  abdominal  wall.  In 
that  state  of  affairs  the  haemostatic  forceps  is  applied  under 
the  fingers  in  the  abdominal  incision,  the  distal  end  dip- 
ping down  into  the  cavity.  The  shield  forceps  is  applied 
from  the  same  side  as  the  haemostatic  forceps,  and  a  retrac- 
tor is  used  to  keep  the  side  of  the  abdominal  wall  and  intes- 
tines away  from  the  point  of  the  forceps  while  the  heat  is 
being  applied. 

Cutting  away  the  tumor  or  tube  and  ovary  is  always 
a  serious  matter,  owing  to  the  tendency  of  the  septic  con- 
tents to  escape  and  contaminate  the  stump  and  wound; 
to  some  extent  this  is  always  the  case  when  the  ligature 
is  used.  The  desired  object  is  accomplished  by  not  mak- 
ing traction  upon  the  parts  to  be  removed  while  the  heat 
is  being  applied.  When  the  pedicle  is  thoroughly  desic- 
cated the  part  to  be  excised  joining  the  forceps  becomes 
closed  by  the  heat  sufficiently  to  prevent  leaking  after  being 
divided.     With  a  sharp  knife  the  parts  are  cut  close  to  the 


54 


ELECTRO-HiEMOSTASIS  IN   OPERATIVE  SURGERY. 


forceps,  while  care  is  taken  not  to  make  pressure  on  tlie 
tube  and  force  out  its  contents. 

In  pyosalpiux  complicated  by  firm  and  extensive  ad- 
hesions the  operation  is  altogether  different.  The  outer 
ends  of  the  tube  and  ovary  are  freed  from  adhesions  until 
the  ovarian  artery  is  reached  and  that  portion  of  the  broad 
ligament  caught  in  the  forceps,  closed  with  pressure  and 
heat  and  divided.  This  liberates  the  tube  and  ovary  so 
that  they  can  be  brought  out  through  the  wound  (in  case 
the  adhesions  of  the  tube  are  not  very  firm),  and  the 
uterine  end  of  the  tube  and  the  remaining  portion  of  the 


Electro-therinic  clamp 
on  tube  and  utero- 
ovarian  ligament. 


Clamp  on  ova- 
rian artery. 


Outer  end  of  1.5'f.'''"\ 

distended 
tube. 


Round       ligament '■'      ,>.  , 
drawn  forward.  V^ 


Fig.  36. — Removal  of  diseased  tube  and  ovary  by  the  forceps.      Partly  diagram- 
matic. 


mesosalpinx  can  be  grasped  mth  the  hysterectomy  forceps 
or  haemostatic  clamp,  sealed  up,  and  the  tube  and  ovary  cut 
away.     (See  Figs.  36  and  37.) 

If  the  tube  is  distended  close  up  to  the  uterus  and  the 


ELECTRO-H^MOSTASIS  IN  OVARIO-SALPINGECTOMY. 


55 


adhesions  are  extensive,  the  operation  has  to  be  modified 
still  more.  After  closing  the  ovarian  artery  and  dividing 
that  portion  of  the  pedicle,  the  ends  of  the  tube  and  ovary 
are  dropped  back,  and  the  foi'ceps  having  been  applied  to 


Lifted  tube  and 
ovary. 


Ovarian  artery.    •-'       )  j^.jj„-v'.'  ] 


Bisected      stump    ,.•:'  ***='ijvj  l-' 
of  ovar to-pelvic,-''  '-^■"^^^O.A'i 


ligament 


Broad  ligament  /'  ^^.fi'-^ 
with  large  tor---''  <C-^^/'i 
tuous  veins. 


Fig.  37. — Second  step  of   palpingo-oophorectomy  whenever  the  broad-ligament 

veins  are  enlarged. 

the  tube  close  up  to  the  uterus,  they  are  thoroughly  com- 
pressed and  desiccated,  and  then  divided  in  the  line  of  the 
closed  portion  of  the  tube.  A  traction  forceps  is  applied 
to  the  end  of  the  tube  to  keep  it  from  falling  back  into 
the  pelvic  cavity.  The  separation  of  the  adhesions  is  com- 
pleted and  the  tube  and  ovary  brought  out  of  the  wound, 
and  the  remaining  pedicle — that  is,  the  mesosalpinx — treated 
in  the  usual  way  with  a  small  haemostatic  forceps.  If  the 
adhesions  are  old  and  vascular  there  is  generally  some 
oozing  from  the  raw  surface  of  the  broad  ligament,  and 
this  should  be  stopped  by  passing  the  dome  cautery 
heated  to  185°  or  190°  over  the  oozing  surfaces  until  they 
are  dry. 

If  the  tubes  are  largely  distended  and  their  walls  are 
thin,  the  adhesions  should  be  separated  only  where  that 


56  ELECTRO-H^MOSTASIS  IN   OPERATIVE  SURGERY. 

can  be  easily  done ;  tlie  tubes  are  emptied,  or  partially  so^ 
with  the  aspii'ator,  and  then  seized  with  the  forceps  and 
brought  out.  The  adhesions  should  be  separated  by  divid- 
ing them  with  scissors,  or,  if  very  vascular,  the  haemostatic 
forceps  should  be  used.  The  pedicle  is  then  treated  in 
one  mass  or  in  three  sections  as  last  described. 

When  both  tubes  and  ovaries  are  diseased,  especially  in 
double  pyosalpinx,  the  uterus  should  also  be  removed. 
The  operation  is  then  performed  in  exactly  the  same  way  as 
abdominal  hysterectomy  for  uterine  fibromata. 


CHAPTER   A^II 

ELECTEO-H^MOSTASIS    IX    APPENDECTOMY 

FiNDZNG  that  the  treatment  of  the  pedicle  of  ovarian 
tumors  with  compression  and  heat  applied  with  the  electric 
current  gave  infinitely  the  best  results,  I  employed  the 
same  method  in  appendectomy  with  equally  fortunate  and 
gratifying  success. 

That  the  same  secondary  troubles  followed  append- 
ectomy as  after  removal  of  the  Fallopian  tube  was  appar- 
ent on  reading  the  records  of  many  surgeons.  A.  Lapthorn 
Smith  says  that  he  had  several  cases  from  one  to  two  years 
after  the  appendix  had  been  removed,  who  were  suffering 
fi^om  fecal  fistula  or  pericsecal  abscess.  This  is  about  the 
same  as  the  testimony  of  Armstrong  also,  who  reported  in 
the  British  Medical  Joui'nal,  October  9,  1897,  that  fecal 
fistula  followed  fifteen  times  in  five  hundred  and  forty-one 
cases.  A.  Lapthorn  Smith  very  clearly  states  that  "  because 
of  the  mucous  glands  which  are  imbedded  in  the  mucous 
membrane  of  the  appendix,  it  is  quite  as  unsurgical  to  put 
a  ligature  around  the  base  of  the  appendix  a  (juarter  of  an 
inch  fi'om  the  caecum  and  then  cut  the  appendix  off,  as  to 
propose  to  close  an  opening  in  the  bowel  by  picking  up 
the  edges  of  the  opening  and  tying  a  ligature  around  them, 
because  this  would  simply  bring  mucous  surfaces  into  con- 
tact, and,  when  the  ligature  has  cut  through  or  has  other- 
wise fallen  off,  the  secreting  glandular  surface  would  sejDa- 
rate  and  the  contents  of  the  bowel  escape.  Those  who 
follow  this  method  may  say  that  they  cauterize  the  mucous 
membrane  after  cutting  off   the    appendix,   and  not    only 

57 


58  ELECTRO-H^MOSTASIS  IN   OPERATIVE   SURGERY. 

disinfect  it  but  also  destroy  its  secreting  surface.  But 
this,  I  maintain,  it  is  impossible  for  them  to  do,  because  they 
manifestly  can  not  reach  the  mucous  membrane  brought 
together  by  the  ligature,  and  still  less  that  part  of  it  which 
lies  below  the  ligature.  If  there  were  only  one  case  of 
fecal  fistula  instead  of  fifteen  in  five  hundred  it  would  be 
worth  while  preventing  it. 

"  The  ideal  method,  in  my  opinion,  and  which  I  have 
followed  in  these  cases,  is  for  an  assistant  to  hold  up  the 
intestine  an  inch  on  one  side  of  the  appendix,  and,  after 
tying  and  cutting  the  meso-appendix,  to  snip  the  appendix 
off  even  with  the  caecum.  The  hole  in  the  intestine  is 
then  sewed  up  with  tine  silk,  care  being  taken  to  include 
the  muscular  coat.  A  director  is  then  pressed  upon  the 
line  of  the  suture  until  it  sinks  below  the  surrounding 
surface,  when  another  row  of  sutures  brings  the  peritoneal 
surfaces  together.  Such  a  closure  will  almost  surely  unite 
by  primary  union,  doing  away  with  all  danger  of  fecal 
fistula  or  circumcaecal  inflammation,  by  which  the  opening 
in  the  appendix  is  sometimes  closed,  and  in  which  cases, 
although  there  is  no  fecal  fistula,  the  patient  is  subjected 
to  a  good  deal  of  discomfort  while  Nature  is  throwing  out 
a  layer  of  plastic  lymph  to  seal  the  defective  closure. 
Some  authors  recommend  the  peeling  off  of  the  peritoneal 
coat  of  the  appendix,  so  as  to  form  a  cuff  a  quarter  of  an 
inch  long,  and  then,  after  tying  and  cutting  off  the  appen- 
dix in  the  manner  which  is  condemned  above,  make  up 
for  the  defect  by  sewing  the  peritoneum  over  the  end  of 
the  stump.  This  is  much  better  than  leaving  a  slough- 
ing stump  free  in  the  abdomen,  but  it  is  by  no  means  as 
good  as  the  method  advocated  above,  in  which  no  stump 
at  all  is  left,  and  nothing  but  a  fine,  thin  line  of  Lembert 
suture,  which  we  know  gives  absolutely  no  trouble." 

This  same  method,  described  above,  was  fully  given  by 
Haggard,  of  Nashville,  in  a  paper  reported  in  the  Trans- 
actions of  the  Southern  Surgical  and  Gynaecological  Asso- 
ciation,  at   the  tenth    annual    meeting   in   St.  Louis,  last 


ELECTRO-H^MOSTASIS  IN  APPENDECTOMY.  59 

November.  He  summed  up  its  merits  as  follows  :  "  Total 
excision  of*  the  appendix,  with  closure  of  the  hole  in  the 
head  of  the  colon,  was  said  to  do  away  with  the  following 
dangers :  (1)  Subsequent  perforation  of  the  stump  under 
the  ligature  from  infection  in  its  own  cavity  ;  (2)  abscess 
of  the  wall  of  the  csecum  from  invagination  of  the  infected 
stump ;  (3)  continuance  of  the  infected  process  from  stric- 
ture in  the  stump  between  distal  ligature  and  the  proximal 
opening  of  the  appendix  into  the  caecum ;  (4)  imperfect 
invagination,  with  the  incomplete  drainage  of  the  stump, 
on  account  of  the  csecal  wall  being  thickened  and  stiffened 
with  inflammatory  exudate." 

I  have  not  had  an  opportunity  of  examining,  post 
mortem,  the  stump  treated  with  the  haemostatic  forceps, 
but  have  observed  clinically  that  during  the  reparative 
process  no  immediate  exudation  can  be  detected ;  neither 
have  there  been  any  remote  inflammations  or  exudates  found 
on  examination  that  caused  pain  or  any  other  symptoms. 
The  recovery  has  been  complete  and  permanent.  This  is 
as  might  be  expected,  from  the  fact  that  the  lumen  of  both 
the  tubes  and  the  blood-vessels  is  completely  obliterated 
by  compression  and  heat,  and  does  not,  in  fact  can  not, 
reopen.  That  complete  disorganization  of  the  mucous 
membrane  of  tubes  or  vessels  and  permanent  closure  of 
their  lumen  are  affected  has  been  demonstrated  in  the 
several  experiments  detailed  in  the  third  chapter  of  this 
work. 

This  experience  in  ovariotomy  and  kindred  operations 
led  me  to  expect  equally  satisfactory  results  in  append- 
ectomy, and  my  expectations  have  been  fully  realized  in 
practice.  In  fact,  this  method  of  treating  the  stump  of  the 
appendix  has  special  advantages  in  being  the  only  satisfac- 
tory way  of  controlling  haemorrhage  in  softened  septic  tis- 
sues, as  well  as  closing  the  appendix  itself. 

In  salpingectomy,  ovariotomy,  and  appendectomy  the 
surgeon  often  finds  that  the  pedicle  or  point  of  separation 
is  diseased,  and  the  ligature  is  likely  to  cut  the  tissues  if 


60  ELECTRO-H^MOSTASIS  IX   OPERATIVE   SURGERY. 

made  tight  enougli  to  close  tlie  vessels ;  and  even  if  that 
mishap  is  avoided  the  stump  is  infiltrated  with  septic  ma- 
terial, which  causes  trouble  no  matter  how  sterile  or  asep- 
tic the  ligature  mav  be.  With  the  haemostatic  forceps  the 
vessels  and  lumen  of  the  tube  or  appendix,  as  the  case  may 
be,  are  completely  closed  and  the  stump  thoroughly  disin- 
fected at  the  same  time.  I  have  had  abundant  opportuni- 
ties to  prove  the  advantages  of  this  method  of  controlling 
bleeding  vessels  in  pelvic  surgery.  I  am  now  using  it  in 
other  branches  of  surgery  with  equally  satisfactoiy  results. 

The  following  case  history  is  giv^en  as  reported  by  a 
clinical  assistant : 

W.  S.  P.,  aged  thirty-two  years;  a  New  York  mer- 
cliaut,  of  medium  build,  active  disposition,  neuro-sanguine 
temperament,  regular  habits  ;  primary  assimilation  and  ulti- 
mate nutrition  good.  Physical  examination  reveals  appar- 
ently perfect  health.  Complaint  is  made  for  the  past 
month  of  a  dull  ache  in  the  right  iliac  region,  usually 
merely  annoying,  but  at  times  severely  lancinating  and 
markedly  distressing.  There  are  no  other  symptoms,  either 
.gastric  or  intestinal,  except  that  the  bowel  is  inclined  to 
constipation. 

A  physical  examination  was  easily  made  because  of  the 
laxity  of  the  abdominal  wall,  and  revealed  a  small  movable 
tumor  in  the  region  of  the  appendix. 

The  patient's  condition  does  not  prevent  Ms  continu- 
ance in  the  regular  duties  of  his  business  ;  yet,  in  view  of  a 
history  of  six  other  attacks,  he  seeks  relief  from  the  pain 
and  mental  disquiet  by  operative  procedure. 

The  patient  enjoyed  good  health  until  two  years  ago 
last  Fall.  The  first  attack  was  provoked,  apparently,  by 
a  bath  immediately  after  dinner.  The  local  symptoms 
were  typical  of  an  inflammatory  condition  of  the  ap2:)endix 
vermiformis.  The  pain  at  first  was  general  over  the  abdo- 
men, beginning  in  the  epigastrium,  but  soon  became  local- 
ized in  the  right  iliac  fossa.  After  four  or  five  days  of 
rest  and  medication  relief  was  obtained,  and  the  regular 


ELBCTRO-H^MOSTASIS  IN  APPENDECTOMY. 


61 


business  duties  were  resumed.  In  February,  1896,  while 
suffering  from  a  severe  cold,  a  second  attack  prostrated  the 
patient.  At  this  time  the  pain  was  at  once  localized  in 
the  region  of  the  appendix,  and  recovery  under  treatment 
was  retarded  for  nearly  two  weeks.  Again,  in  May,  1896, 
after  partaking  heartily  of  lobster,  the  patient  was  seized  in 
a  similar  manner  for  the  third  time.  On  this  occasion  his 
condition  was  deemed  so  critical  that  he  was  advised  to 
submit  to    an   immediate  operation.      After   nine   or   ten 


Fig.  38. — First  seizure  by  forceps  in  appendectomy.     The  heating  forceps  grasps 
the  meso-appendix,  the  shield  forceps  protecting  the  bowel. 

days,  however,  he  was  relieved  by  medical  treatment,  and 
in  a  short  while  was  able  to  attend  to  his  business  duties. 
Six  months  later.  Thanksgiving  Day,  1896,  an  extended 
railroad  trip  was  suddenly  interrupted  by  a  fourth  attack 
similar  to  the  preceding  ones.  This  was  followed  by  a 
fifth  in  February,  1897,  and  a  sixth  in  May  of  the  same 
year. 

The  attacks  were  all  similar  in  their  onset,  nature,  and 


62 


ELECTRO-H^MOSTASIS  IN  OPERATIVE   SURGERY. 


course.  The  pain  came  suddenly,  without  any  premonitory 
symptoms,  and  after  the  first  time  it  was  at  once  localized 
in  the  region  of  the  appendix ;  there  ^vas  no  gastric  dis- 
turbance except  a  slight  nausea,  nor  intestinal,  except 
tympanites ;  relief  followed  the  exhibition  of  opium  and 
local  hot  comj^resses.  At  the  present  time  of  comparative 
quiescence,  and  while  he  is  yet  in  first-class  condition  to 
bear  an  operation,  the  patient  has  at  last  consented  to  the 
repeatedly  advised  surgical  interference. 

The  operation  was  done  Janu- 
ary 11,  1898.  For  the  first  time 
iu  the  history  of  appendectomy  the 
method  of  operating  mth  the  elec- 
tric haemostatic  forceps  was  fol- 
lowed. This  de2:)arture  from  the 
current  methods  of  ligature,  su- 
ture, cauterization,  invagination,  and 
others  is  the  logical  outcome  of  the 
success  of  this  practice  \vhen  operat- 
ing upon  the  pelvic  viscera.  All 
the  other  steps  of  the  operation 
were  such  as  are  advised  by  sur- 
geons generally.  The  incision  was 
the  ordinary  one  over  McBurney's 
point,  two  inches  in  length.  On  in- 
FiG39.-Compieted  treatment  gpectiou,  both  the  appendix  and  the 

of   mesentery  in   appendec-      -■-  '  .  -•-  -L 

tomy.     The  scissors  have  bi-    meSO-appCudix     WCrC     f  OUud     to     be 

sected  the  seizure.  •,  -,  t  -i     ,t  •   i  i  -i 

much  enlarged  and  thickened,  and 
supeiUcially  traversed  by  numerous  dilated  blood-vessels. 
There  were  no  adhesions.  The  first  grasp  of  the  forceps 
was  upon  the  meso-appendix  close  to  its  mesenteric  at- 
tachment. (See  Fig.  38.)  A  current  which  heated  the 
forceps  to  180°  F.  was  then  induced  for  half  a  minute. 
Upon  removal  of  the  forceps  the  tissues  were  found  to  be 
not  charred  but  dried,  having  the  appearance  of  white 
homy  matter.  Scissors  were  used  to  bisect  this  desiccated 
area.     (See  Fig.  39.)     A  second  seizure  was  made  upon 


ELECTRO-H^MOSTASIS  IN"  APPENDECTOMY.  63 

the  appendix  itself  close  to  the  caput  coli,  and  the  same 
current  continued  for  ninety  seconds.      The  forceps  was 


Fig.  40. — Second  seizure  of  forceps  in  appendectomy.  The  dried  surface  of  th© 
first  seizure  has  been  bisected.  The  appendix  is  grasped.  The  shield  for- 
ceps are  shown  faintly. 

then  removed  and  the  tissue  divided  in  the  line  of  the 
desiccated  area  away  from  the  caput.  (See  Figs.  40  and 
41.)  The  same  result  was  mani- 
fested. ISo  charred  tissue,  no 
bleeding,  and,  more  important  than 
all,  no  escape  of  the  contents  of 
the  appendix.  The  tissues  had 
simply  been  dried  out.  Just  at 
this  point  a  rather  violent  attack 
of  retching  came  upon  the  pa- 
tient, which  continued  for  nearly 
a  minute,  yet  without  inducing 
any     change     whatever     in     the 

stump.       All    the    severe    pressure    Fig.  41.— stump  after  appendec- 

and    strain    had  not  forced  even     tomy,  showing  the  two  seizures. 
a  speck  of  blood  or  serum  into  the  compressed  area. 
The  abdominal  cavity  was  left  perfectly  free  from  any 


64  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

foreign  matter  whatever.  Sutures  and  dressings  as  usual. 
Time  of  operation  fifteen  minutes. 

iVnaestbetic,  Schleieli  solution  No.  3,  nine  drachms.  Time 
for  induction  of  narcosis,  seven  minutes. 

The  specimen  measures  seventy-five  millimetres  in  length 
and  forty-five  millimetres  in  circumference,  and  is  of  an 
irregular  8  shape.  The  contents  were  about  a  drachm  of 
pus,  mucus,  and  broken-down  cellular  tissue.  The  meso- 
appendix  is  also  much  thickened,  even  to  ten  millimetres, 
and  its  greatest  width  is  twenty  millimetres, 

A  microscopic  section  made  shortly  after  the  operation, 
according  to  the  Johns  Hopkins  "  fifteen-minute  "  method, 
confirmed  the  diagnosis  by  revealing  the  typical  structure 
of  an  old  recurrent  hypertrophied  inflammatory  change. 

The  convalescence  has  been  unmarked  by  any  compli- 
cations due  to  the  operation.  When  the  sutures  were 
removed  after  a  week  the  parietal  wound  was  perfectly  dry 
and  clean.  At  the  close  of  another  week  the  patient  was 
sitting  up,  enjoying  his  newspaper  and  cigar,  and  was  dis- 
charged from  our  care  on  the  seventeenth  day.  He  was 
seen  eight  mouths  after  the  operation,  and  reported  that 
his  health  had  been  perfect,  and  that  he  had  had  no  pain 
or  tenderness  in  the  region  of  the  operation. 

I  do  not  expect  the  judicious,  cautious  surgeon  to 
accept  the  history  of  this  one  case  as  evidence  of  the 
superiority  of  this  method  to  others  that  have  been  tried 
more  fully ;  but  my  experience  with  it  gives  me  full  con- 
fidence that  the  verdict  rendered  by  a  full  and  fail'  trial 
will  be  favorable  in  the  highest  degree. 


CHAPTEE  YIII 

TREAT^rEXT     OF     CA:N"CEE     OF    THE    ETEEUS     BY    THE    ELECTEO- 
CAUTEEY    AXD    HiEMOSTASIS 

DuEEs^G  the  past  few  years  tlie  treatment  of  cancer  of 
the  uterus  has  been  vaginal  hysterectomy  almost  exclu- 
sively, and  upon  theoretical  grounds  that  appears  to  be 
the  most  appropriate  way  of  dealing  mth  this  disease. 
Yet  a  careful  comparison  of  all  methods  practiced  leads  to 
the  conclusion  that  other  methods  of  operative  treatment 
are  called  for  in  certain  conditions  and  give  better  results 
than  any  one  operation. 

The  unprejudiced  observer  who  has  read  the  writings 
of  Dr.  John  Byrne,  and  has  seen  his  work  and  the  results 
in  amputation  of  the  cervix  uteri  Avith  the  galvano-cautery, 
will  be  convinced  that  this  practice  is  worthy  of  the  sur- 
geon's confidence.  In  veiy  recent  times,  that  is  in  1895, 
Dr.  Kelly  and  Dr.  Clark  reported  a  more  radical  method 
of  aljdominal  hysterectomy  for  cancer,  which,  judging  from 
theii'  subsequent  results,  also  merits  attention  and  appears  to 
meet  the  requirements  in  advanced  cases  of  cancer  of  the 
uterus. 

In  my  own  practice  at  the  present  time  I  choose  the 
operation  best  adapted  to  the  stage,  location,  or  condition 
of  the  disease  in  question.  The  condition  or  character  of 
the  disease  and  its  location  presents  several  forms. 

In  the  majority  of  cases  the  disease  begins  in  the  cervix. 
In  some  the  tissues  around  the  os  externum  are  first  in- 
volved and  the  new  tissue  grows  downward  into  the 
vagina.     Fig.  42  illustrates  this  stage,  in  vrhich  only  the 

65 


fi6 


ELECTRO-H^MOSTASIS  IN  OPERATIVE   SURGERY. 


lower  or  vaginal   portion  of  the  cervix  is  involved.     In 
other  cases  the  disease   begins  in  the  mucous  membrane 


Fig.  42. — Malignant  disease  of  cervix  developing  downward.     A,  seen  in  section ; 
B,  as  seen  through  Sims's  speculum. 

within  the  cervical  canal  and  dilates  the  cervix  extensively 
before  it  protrudes  into  the  vagina.    (See  Fig.  43.)     A  con- 


'S^ftu.. 


YiG.  43. — Malignant  disease  of  cervix  beginning  in  cervical  canal.     A,  seen  in  sec- 
tion;  B,  seen  through  Sims's  speculum. 

dition  which  resembles  this  is  that  in  \vhich  the  disease 
begins  in  the  lower  part  of  the  cervix  and  extends  upward 


TREATMENT  OF  CANCER  OF  THE  UTERUS. 


67 


into  the  cervix  wliile  the  portion  that  protruded  into  the 
vagina  has  sloughed  ofl*.  In  rare  cases  the  disease  begins 
in  the  body,  or  fundus  uteri.  In  the  first  condition  de- 
scribed amputation  vrith  the  galvano-cautery  ecraseur  is 
called  for.  In  the  next  state  high  amputation  is  required 
with  the  cautery  knife.  In  the  last  condition  mentioned, 
cancer  in  the  corpus  uteri,  hysterectomy  is  the  only  opera- 
tion indicated.  These  operations  I  shall  describe  in  the 
order  named. 


Amputation  of  the  Cervix  Uteri  tvith  the  Galvano-cautery  Ecraseur. 

Dr.  John  Byrne  having  been  the  first  to  operate  suc- 
cessfully with  the  galvano-cautery  and  continuing  to  be  the 


Fig.  44. — Byrne's  speculum  for  vaginal  hysterectomy. 

highest  authority  on  the  subject,  I  shall  give  his  descrip- 
tion of  the  operation.  First,  in  regard  to  the  exposure  of 
the  part  to  be  amputated.  Dr.  Byrne  uses  his  own  sjDecu- 
lum,  which  he  describes  as  follows :  "  The  instrument  re- 
ferred to  is  the  speculum  introduced  and  described  by  me 
about  fifteen  months  ago,  and  a  modification  of  which  is 
here  shown  (Fig.  44). 

"This  speculum,  it  mil  be  observed,  differs  none  in 
principle  from  that  previously  noticed  ;  and  as  to  the"  sev- 
eral pieces  of  which  it  is  composed,  they  may  be  considered 
the  same,  with  one  exception — namely,  the  frame  on  which 
the  lower  or  perineal  blade  moves  is  much  wider  and  a 
little  longer,  thereby  affording  more  working  space  and 


68 


ELECTRO-H.EMOSTASIS  IX   OPERATIVE   SURGERY. 


greatly  facilitating  operative  manipulations.  The  fore- 
shortened view  in  the  above  sketch  will  serve  to  explain 
more  clearly  the  points  of  difference  between  this  '  operat- 
ing '  and  the  ordinary  speculum. 

"  Some  advantages,  however,  will  be  found  by  having 
the  intra  vaginal  parts  of  this  instrument  a  little  longer^ — 
say  half  an  inch — and  from  one  quarter  to  three  eighths 
wider  than  the  ordinary  size.  I  have  also  occasionally  re- 
sorted to  a  piece  of  bent  spring  wire,  to  be  introduced  after 


Fig.  45. — Byrne's  speculum  in  position. 

the  speculum  has  been  adjusted  and  the  uterus  fixed  in 
position,  for  the  pui'pose  of  still  further  separating  the 
lateral  walls.  This,  though  by  no  means  an  indispensable 
requisite  in  any  case,  may  nevertheless  be  made  to  render 
good  service,  under  certain  circumstances,  and  on  this  ac- 
count I  have  given  directions  to  have  some  such  device 
supplied  with  each  '  operating '  speculum. 

"  Fig.  45  is  intended  to  represent  more  clearly  the  prin- 
ciples on  which  this  speculum  is  constructed  and  the  modus 


TREAT3IEXT   OF   CANCER   OF   THE   UTERUS.  69 

operandi  by  which  the  curved  vaginal  canal  is  not  merely 
dilated  but  straightened  by  pressing  back  the  perineum 
helow,  while  the  vesical  wall  is  elevated  above.  The  under 
blade,  it  will  be  noticed,  is  made  to  move  in  a  circle  in 
which  the  center  is  indicated  by  its  point,  so  that  the  rela- 
tions of  the  latter  to  the  cul-de-sac,  when  the  instrument  is 
first  introduced,  does  not  materially  change,  no  matter  to 
what  extent  the  perineal  blade  may  be  pressed  backward. 
The  various  directions,  too,  in  which  the  upper  double  rod 
may  be  made  to  move  is  a  most  important  feature  in  the 
instrument ;  for,  however  displaced  a  uterus  may  be,  more 
especially  if  anteverted,  and  provided  no  firm  adhesions 
exist,  there  is  no  difiiculty  in  bringing  it  into  view,  and  so 
fixing  it  for  examination  or  treatment. 

"Fig.  46  represents  an  improved  loop  instrument." 
In  operating  for  epithelioma  of  the  cervix  uteri  charac- 
terized by  exuberant  outgro^\iihs  from  a  base,  Dr.  Bj^rue 
places  the  patient  upon  the  back,  exposes  the  cervix  with 
his  speculum  and  applies  the  platina  wire  loop  as  high  up 
in  the  cervix  as  possible,  and  made  moderately  tight,  the 
heat  is  applied  and  little  or  no  contraction  of  the  loop  being 
affected  for  a  few  seconds,  so  that  the  tissues  to  be  cut  may 
be  thoroughly  cauterized. 

Ti'action  by  the  cautery  instrument  should,  in  all  cases, 
be  carefully  avoided  and  the  instrument  kept  steady  and  in 


Fig.  46. — Byrne's  cautery  loop. 


the  same  position  from  the  beginning  to  the  end  of  the  oper- 
ation. 

The  loop  should  be  slowly  and  very  moderately  tight- 
ened just  enough  to  follow  up  the  tissues  as  they  are  divided 
by  the  cautery  heat.     When  the  tissues  are  firm  enough  to 


YO  ELECTRO-H^MOSTASIS  IN  OPERATIVE   SURGERY. 

stand  traction,  the  part  to  be  cut  off  sLoulcl  be  seized  with 
a  forceps  and  traction  made  continuously  while  the  amputa- 
tion is  going  on.  This  leaves  a  dome-  or  cup-shaped  stump, 
thereby  removing  the  central  tissues  higher  up. 

AVhen  the  portion  of  the  cervix  is  conical  and  the  cautery 
loop  is  difficult  to  apply,  Dr.  Byrne  has  employed  the  fol- 
lowing ingenious  method  of  operating,  which  I  have  taken 
from  one  of  his  histories  of  an  operation : 

"A  large-sized  rubber  crochet  needle,  rounded  at  the 
end,  was  heated  and  slightly  bent  so  as  to  accommodate 
itself  to  the  curve  of  the  sacrum  and  posterior  contour  of 
the  tumor. 

"  A  small  hole  was  drilled  transversely  near  its  distal 
extremity,  and  at  right  angles  with  the  direction  of  its 
curve,  and  through  which  a  stout  platina  wire  was  passed 


r 


Pig.  47. — Byrne's  special  loop  carrier. 


half  its  length.  The  fi'ee  ends  of  the  ware  were  now  passed 
through  two  copper  tubes,  each  three  sixteenths  of  an  inch 
in  diameter  and  eight  inches  long,  and  bent  nearly  the 
same  as  the  rubber  rod.  Fig.  47. 

"An  anaesthetic  having  been  administered,  and  the 
patient  placed  on  her  left  side,  the  two  tubes  with  the 
rubber  rod  between  were  carried  behind  the  tumor  as  far  up 
as  deemed  safe.  The  rubber  support  being  now  intrusted 
to  an  assistant,  and  maintained  steadily  in  position,  one  of 
the  copper  tubes  was  carried  around  half  the  circumference 
of  the  tumor,  the  wire  being  pushed  up,  piece  by  piece, 
from  below,  and,  when  the  center  anteriorly  had  been 
reached,  was  so  held  until  the  opposite  half  had  been  en- 
circled in  like  manner.  Two  small  pieces  of  wood,  each 
one-inch  copper  conductors,  were  one  after  the  other  slipped 
up  so  as  to  unite,  yet  insulate  the  latter. 


TREATMENT  OP  CANCER  OF  THE  UTERUS. 


71 


"  This  being  accomplislied,  tlie  free  ends  of  the  platina 
wire  were  next  passed  through  a  modification  of  the  loop 
instrument  as  shown  in  Fig.  48  and  the  copper  conductors 
firmly  fastened  in  the  socket.  All  being  now  in  readiness, 
the  battery  connections  were  made,  when  the  heated  wire 
cut  through  the  rubber  support  and  imbedded  itself  in  the 
substance  of  the  tumor. 

"The  rubber  rod  was  now  withdrawn,  and  the  loop 
very  slowly  contracted,  the  time  occupied  in  cutting  through 
the  whole  mass  being   fully  thirty  minutes,  exclusive   of 


Fig.  48, — Method  of  passing  loop  around  tumor. 

necessary  interruptions.  There  was  no  haemorrhage  from 
the  stump,  but  the  vagina  was  tamponed  as  a  precautionary 
measure." 


HIOH    AMPUTATION 


In  conditions  admitting  of  high  amputation,  the  follow- 
ing is  the  method  usually  resorted  to  :  The  uterus  is  to  be 
exposed  and  the  vaginal  walls  protected  in  the  manner 
already  described.  The  diverging  volsellum  (Fig.  49), 
after  being  passed  well  into  the  cervical  canal,  should  now 
be  expanded  to  a  proper  degree  and  locked,  so  as  to  afford 
complete  control  of  the  uterus  during  the  entire  operation. 


72  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

By  alternate  traction  and  upward  pressure  of  the  uterus^ 
an  accurate  idea  may  now  be  obtained  as  to  the  proper 
point  to  begin  the  circular  incision,  so  as  to  avoid  injuring 
the  bladder  or  opening  into  the  cul-de-sac  of  Douglas.  As 
to  the  latter,  however,  should  it  be  found  that  the  disease 
has  involved  the  retro-uterine  tissues,  and  that  its  excision 
or  destruction  by  the  cautery  can  not  be  effected  without 


Fig.  49. — Diverging  volsellum. 

opening  into  the  peritoneal  cavity,  there  need  be  no  hesita- 
tion in  doing  so.  I  have  never  known  any  harm  to  come 
from  it  whether  it  was  done  accidentally  or  by  design. 
Should  it  be  evident  at  the  outset  that  the  operation,  in 
order  to  be  thorough,  must  include  a  portion  of  the  cul-de- 
sac,  it  will  be  better  to  make  the  line  of  incision  anterior  to 
this,  until  the  cervix  has  been  removed,  and  leave  the  inci- 
sion of  the  retro-uterine  parts  hy  the  cautery  hnife  to  be  the 
final  proceeding.  Under  these  circumstances  all  that  will 
be  needed  will  be  an  antiseptic  tampon  properly  applied. 

In  proceeding  to  make  the 
circular    incision     the    cautery 
knife  (Fig.  50),  slightly  curved 
s  and  cold,  should  be  applied  close 

Fig.  50.—^,  straight  cautery  knife,    up  to  the  vaginal  I'unction,  and 

B,  curved  cautery  knife.  pi  i 

from  the  moment  that  the  cur- 
rent is  turned  on,  should  be  kept  in  contact  with  the  parts 
being  incised  (Figs.  51  and  52). 

Before  removing  the  electrode  for  any  purpose,  such  as 
change  of  position,  or  altering  the  curve  of  the  knife,  the 
current  should  first  be  stopped  and  the  instrument  again 
placed  into  position  while  cool  before  resuming  the  incision. 
In  other  words,  if  the  hnife^  though  heated  only  to  a  dull  red^ 


TREATMENT  OF  CANCER  OP  THE  UTERUS. 


T5 


It  is  important  to  add  that,  in  carrying  the  knife  toward 
the  sides  of  the  cervix,  circular  and  other  arteiial  branches 


Fig.  54. — Cervix  having  been  excised,  the  dotted  lines  indicate  higher  incisions. 

are  likely  to  be  encountered,  and  hence,  in  this  locality  par- 
ticularly, a  high  degree  of  heat  in  the  platinum  blade  is  to 
be  carefully  avoided.  As  an  additional  security  against 
haemorrhage,  the  convexity  of  the 
knife   should  be  pressed  against 

,1  i  1  i?  J?  1     „         Fig.  55. — Dome-shaped  electrode. 

the  external  surface  oi  each  par-  ^ 

ticular  section  cut,  so  as  to  close  the  vessels  more  effectually. 

(Figs.  56  and  57.) 

It  is  well  to  state  that  the  metallic  parts  of  the  elec- 
trode for  the  distance  of  about  two  inches  should  he  covered 
with  a  strip  of  thin  flannel^  so  that  the  vagina  may  he  pro- 
tected from  injury  through  the  refected  heat. 

VAGINAL    HYSTERECTOMY    IN    CARCINOMA    UTERI 

Vaginal  hysterectomy  offers  superior  opportunities  for 
the  use  of  the  haemostatic  forceps  in  arresting  haemorrhage. 
I  have  tried  every  known  method  of  doing  this  operation. 


<6 


ELECTKO-H^MOSTASIS  IX  OPERATIVE  SURGERY. 


and  found  them  all  objectionable,  and  so  I  was  led  to  do 
the  operation  as  follows :  The  general  preparation  of  the 
patient  is  the  same  as  for  all  major  oj)erations,  but  the 
cleansing  and  disinfecting  of  the  vagina  is  difficult  and 
requires  s^Decial  care. 

If  the  body  of  the  uterus  alone  is  affected,  the  cervical 
canal  must  be  washed  out,  packed  loosely  with  cotton,  and 
closed  ^vith  a  pair  of  forcex^s  or  with  sutures.     If  the  dis- 


FlG.  56. — High  amputation  by  one  incision.     (Byrne.) 

ease  involves  the  cervix,  so  tliat  the  cancerous  mass  pro- 
trudes into  the  vagina,  it  should  be  removed  with  the  cau- 
tery or  curette,  and  then  the  canal  closed  in  the  manner 
described.  The  object  of  this  closm^e  of  the  canal  is  to 
keep  the  parts  clean  and  fi'ee  from  infection  dming  the 
removal  of  the  uterus. 

It  is  always  difficult  to  make  tlie  vagina  and  external 
genetalia  aseptic,  but  in  cancer  of  the  uterus  it  is  well- 
nigh  impossible.  On  that  account,  I  have  removed  the 
cancerous  gi'owths  from  the  cervix  preliminary  to  hysterec- 
tomy, and  then  made  the  parts  as  clean  as  possible. 


TREATMENT  OF  CANCER  OF  THE  UTERUS. 


81 


metal  core  to  give  strength,  and,  being  poor  conductors  of 
heat,  effectually  protect  the  adjacent  tissues  from  injury. 

A  little  practice  is  needed  in  order  to  know  the  length 
of  time  that  the  heat  should  be  continued.     When  one  is 


Fig.  64. — Diagram  of  seizure  of  upper  portion  of  broad  ligament  when  diseased 
tube  and  ovary  are  to  be  removed  with  uterus. 

doubtful  about  this,  the  forceps  may  be  removed  and  the 
parts  inspected ;  and,  if  need  be,  the  forceps  should  be  re- 
applied and  the  heat  continued  long  enough  to  obtain  the 
desired   effect.     The   lisrament   is    divided   with   knife   or 


82 


ELECTE0-H^3I0STAS1S   IX   OPERATIVE  SURGERY. 


scissors  between  the  forceps  aud  the  uterus  as  far  up  as 
the  vessels  have  been  closed.  The  lower  portion  of  the 
ligament  on  the  other  side  is  treated  in  the  same  way. 
The  uterus  is  drawn  down,  and  the  remaining  portions  of 
the  ligaments  are  treated  in  sections  until  the  uterus  is 
completely  fi'eed.  (See  Figs.  63  and  64.)  The  operation 
may  be  briefly  described  by  sapng  that  it  is  performed  in 
the  same  way  as  Avhen  forceps  are  used  to  control  the 
bleeding  (commonly  called  the  French  method),  with  the 
diiference  that  instead  of  leaving  the  forceps  on  long  enough 
for  the  compression  alone  to  arrest  the  haemorrhage  (twenty- 
four  or  forty-eight  hours),  the  heat  completes  the  hsemo- 
stasis,  and  the  forceps  is  removed  at  once. 

After  the  uterus  is  removed  a  careful  examination  of 
the  parts  should  be  made,  and  if  any  portion  of  the  broad 


Peritoneum. 


Peritoneum. 


YiG.  65. — Diagram  showing  sutures  ready  to  be  tied. 

lio-aments  shows  that  the  disease  has  extended  beyond  the 
uterus,  the  suspected  parts  should  be  removed.  This  is  done 
by  seizing  the  stump  ^vith  a  fixation  forceps  and  making 
traction  enough  to  bring  the  part  within  reach  and  then 
applying  the  haemostatic  forceps  outside  of  the  traction 
forceps  and  desiccating  sufficiently  to  destroy  the  diseased 


TREATMENT  OP  CANCER  OF  THE  UTERUS. 


83 


tissue.  Tlie  cavernous  tissue  is  completely  destroyed  by  the 
electric  heat  applied  in  this  way,  and  the  results  are  as 
good  as  if  the  part  had  been  exsected.  According  to  Dr. 
Byrne,  cancer  can  be  eradicated  in  this  way  at  points  in 
deep  pelvic  structures  that  can  not  be  safely  reached  by  the 
ordinary  methods  of  extirpation. 

The  next  step  is  to  sponge  the  field  of  operation  dry  and 
clean,  and  then  unite  the  peritoneum  to  the  anterior  and 


■  Peritoneum 


Pig.  66. — Diagram  showing  sutures  tied. 

posterior  vaginal  w^alls  with  line  catgut  sutures.  The 
peritoneal  cuts  should  be  sponged  clean.  One  end  of  each 
suture  is  then  cut  off  and  the  remaining  ends  are  tied  to  the 
opposite  sutures,  thus  completely  closing  the  wound,  except 
in  the  center,  where  space  enough  is  left  to  admit  a  small 
gauze  drain.  (See  Figs.  65  and  6Q.)  The  vagina  is  loosely 
packed  with  gauze,  and  the  operation  is  completed. 

The  advantages  which  may  be  fairly  claimed  for  this 
method  of  doing  hysterectomy  are  many  in  favor  of  both 
patient  and  operator.  In  the  first  j)lace,  and  most  desir- 
able, it  is  a  bloodless  operation.  Most  of  the  patients  hav- 
ing cancer  are  anaemic  and  can  ill  afford  to  lose  blood. 
Then  the  operation  can  be  done  in  less  time  than  in  any 


84  ELECTRO-H^MOSTASIS  IN   OPERATIVE  SURGERY. 

other  way,  excepting  by  the  so-called  French  method, 
which  is  most  unsatisfactory  in  its  results,  and  should  not 
be  considered  in  comparing  the  operations.  Again,  there 
is  no  ]3ain  and  little  if  any  constitutional  disturbance.  Be- 
sides, the  time  required  for  recovery  is  the  shortest  on 
record,  and,  judging  by  my  own  experience,  the  mortality 
is  less  than  one  half  of  one  per  cent.  In  addition  to  all 
this,  the  broad  ligament  stumps  are  reduced  to  the  smallest 
size,  the  blood-vessels  and  lymphatics  are  completely  closed, 
and  hence  the  process  of  repair,  which  takes  place  by  reor- 
ganization, is  accomplished  in  very  little  time,  and  the 
thorough  disinfection  of  the  stumps  by  desiccation  guards 
against  reinfection  and  immediate  recurrence  of  the  disease. 
The  time  and  taxation  saved  on  the  part  of  the  surgeon  can 
be  realized  only  by  one  who  has  repeatedly  operated  in 
both  this  and  other  ways. 


CHAPTEE  IX 

THE     ELECTRO-CAUTERY     IK^    THE     TREATMENT     OF     PELVIC    AB- 
SCESS AND    DISEASES    OF   THE  VULVA    AND    VAGINA 

Pelvic  inflammations  ending  in  abscess  were  all  treated 
by  opening  from  the  vagina  in  the  times  when  salpingitis 
and  ovaritis  were  not  understood.  At  that  date  there  were 
many  cases  requiring  such  treatment.  But  after  the  re- 
moval of  diseased  Fallopian  tubes  by  abdominal  section  be- 
came established  surgery,  the  vaginal  route  of  getting  at 
pus  in  the  pelvis  was  given  up.  Within  the  past  few 
years,  and  since  vaginal  hysterectomy  has  been  perfected, 
vaginal  section  has  become  as  popular  as  abdominal  section 
was.  I  never  gave  up  vaginal  section  for  pelvic  abscess  in 
a  given  class  of  cases.  I  refer  especially  to  pelvic  cellulitis 
following  parturition  and  secondary  pelvic  cellulitis  caused 
by  pyosalj^inx  with  extensive  adhesions,  and  in  cases  of 
general  pelvic  inflammation  in  which  the  pelvis  is  filled 
with  the  products  of  inflammation,  so  that  the  organs  first 
involved,  be  they  ovaries  or  tubes,  and  the  site  or  depot  of 
suppuration  can  not  be  removed  by  coeliotomy. 

There  are  really  three  forms  or  conditions  w^hich  call  for 
vaginal  section  :  the  one  a  pyosalpinx,  lying  in  the  most  de- 
pendent part  of  the  sac  of  Douglas  and  bound  down  by 
products  of  inflammation  which  fill  the  upper  part  of  the 
pelvis ;  the  other  where  by  ulcerative  perforation  the  tube 
has  opened  into  the  cellular  tissue  of  the  broad  ligament 
and  there  developed  a  cellulitis  ;  and,  finally,  primary  cellu- 
litis following  parturition  or  septic  injuries  of  the  cervix 
uteri. 

85 


86  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

Treatment — The  preparation  for  the  operation  and  the 
position  of  the  patient  should  be  the  same  as  in  vaginal 
hysterectomy.  The  posterior  fornix  of  the  vagina  being 
exposed  by  retractors,  the  vaginal  wall  should  be  divided 
with  the  cautery  knife,  heated  while  in  contact  with  the 
tissues,  throughout  the  entii-e  width  of  the  cervix  uteri 
and  outward  on  either  side,  in  case  the  cervix  is  small,  for 
half  an  inch.  It  sometimes  happens  that  a  divided  vessel 
bleeds  freely.  That  should  be  controlled  by  seizing  the 
tissue  at  the  bleeding  point  with  a  haemostatic  forceps  and 
heating  until  the  hgemorrhage  is  controlled.  At  this  stage 
of  the  procedure  an  examination  should  be  made  for  fluctu- 
ation or  a  soft  part  in  the  mass  behind  the  uterus.  If  no 
such  spot  is  found,  a  curved  aspirating  needle  should  be 
introduced  to  search  for  pus ;  when  found,  the  needle 
should  be  left  in  place  as  a  guide  for  the  incision  with  the 
cautery.  When  the  incision  is  made  large  enough  to  intro- 
duce the  finger,  a  further  examination  should  be  made  to 
determine  whether  there  is  one  abscess  or  many.  If  the 
latter,  the  walls  between  them  should  be  broken  down  and 
the  cavity  thoroughly  washed  out  with  carbolized  water  or 
such  disinfectant  as  the  surgeon  prefers. 

The  wound  should  be  enlarged  in  case  it  is  not  sufficient 
to  secure  free  drainage.  I  prefer  a  roll  of  gauze,  large 
enough  to  fill  the  wound  and  long  enough  to  extend  up  to 
the  upper  portion  of  the  abscess  cavity.  This  drain  of 
gauze  should  be  removed  at  the  end  of  twenty-four  hours, 
and  the  cavity  again  irrigated  and  the  smaller  gauze  drain 
used.  This  change  of  drains  is  most  easily  made  with  the 
patient  in  Sim's  position.  After  this  a  double  rubber 
drainage  tube  should  be  used  and  held  in  place  by  a  suture, 
carried  through  the  edge  of  the  wound  and  the  tubes.  The 
cavity  should  be  washed  out  daily  until  the  sac  contracts 
down,  then  the  rubber  tubes  should  be  removed  and  a 
small  pledget  of  gauze  placed  into  the  vaginal  wound  until 
the  ca\dty  is  completely  closed. 


ELECTRO-CAUTERY  IN  TREATMENT  OF   PELVIC  ABSCESS.     8Y 
CYSTS    OF   THE    LABIA 

Complete  exsection  is  the  proper  treatment  of  the  cysts 
that  are  quite  frequently  found  in  the  labia.  But  this  has 
proved  to  be  very  difficult  in  my  practice,  and  I  infer  from 
reports  that  others  have  not  been  much  more  successful.  I 
have  tried  in  a  great  many  cases  to  remove  such  cysts  with- 
out rupture^  but  have  invariably  failed.  The  cyst  wall  is 
very  thin,  and  so  closely  adherent  to  the  surrounding  tissue, 
especially  at  the  deepest  part,  that  complete  enucleation  is 
impossible,  so  far  as  my  experience  goes.  Lack  of  success 
drove  me  to  seek  some  more  satisfactory  method  of  operat- 
ing, which  I  found  in  the  following:  In  the  large  cysts 
that  were  near  the  surface,  by  making  a  free  incision  with- 
out wounding  the  cyst  wall,  I  have  succeeded  in  separating 
the  cyst  from  the  greater  portion  of  its  attachment ;  and 
by  retracting  the  sides  of  the  wound  so  that  the  base  of 
the  attachment  was  brought  within  easy  reach,  and  then 
applying  a  narrow-bladed  haemostatic  forceps  to  control 
bleeding  and  compress  the  tissue  and  form  a  stump,  the 
stump  is  divided  at  the  desiccated  point,  and  the  cyst  set 
free  thereby. 

In  some  cases  it  is  necessary  to  separate  the  adhesions 
in  sections ;  that  is  to  say,  a  portion  of  the  cellular  tissue  is 
seized  by  the  forceps,  compressed  and  desiccated,  and  then 
divided  in  the  center  of  the  desiccation  ;  another  portion  is 
treated  in  the  same  way  until  the  cyst  is  completely  liber- 
ated. All  bleeding  being  arrested  by  the  process,  the 
wound  can  be  closed  with  sutures,  and  healing  proceeds 
without  interruption  as  a  rule.  The  cyst  will  be  ruptured 
sometimes,  though  the  greatest  care  be  taken ;  then  the 
next  best  thing  to  do  is  complete  cauterization  of  the  cyst 
wall.  The  wound  is  held  open  with  forceps  or  tenacula 
and  a  fine  cautery  point  or  knife  blade  passed  over  the 
surface  until  every  portion  of  the  cyst  wall  is  cauterized. 
The  cauterization  should  be  very  superficial,  but  complete. 
If  any  portion  of  the  cyst  wall  is  left  undestroyed,  it  will 


88  ELECTRO-H.EMOSTASIS  IN  OPERATIVE   SURGERY. 

continue  to  secrete  and  retard  healing,  or  form  another 
cyst. 

When  cauterization  is  employed,  the  wound  should  he 
left  open  until  the  charred  tissue  separates  and  is  thrown 
off.  When  this  separation  takes  place  it  is  necessary  to 
wash  the  deb?' is  away  or  sponge  it  out  of  the  wound.  The 
healing  process  goes  on  very  rapidly  under  the  crust  of 
charred  tissue,  and  when  this  separates,  the  closure  of  the 
cavity  or  wound  is  completed  in  a  very  short  time. 

This  method  of  operating  upon  labial  cysts  involves 
much  more  time  and  trouble  than  the  old  way,  but  the 
comparatively  little  after-care  required,  the  shorter  time  of 
recovery,  and  the  relief  from  suffering,  more  than  compen- 
sate both  the  patient  and  the  sui^geon. 

CYSTS    OF    THE    VAGLN'A 

These  cysts  of  the  vagina  are  caused  in  some  cases  by  a 
closing  and  distention  of  the  vaginal  glands,  but  they  more 
frequently  are  developed  from  distention  of  Grartner's  ducts, 
a  portion  of  one  of  them  remaining  patent. 

This  has  been  clearly  pointed  out  by  Amand  Routh  in 
his  most  interestino;  article  in  volume  xxx^'  of  the  Transac- 
tions  of  the  Obstetrical  Society  of  London.  Their  recog- 
nition is  not  difficult,  pro\dded  that  a  careful  inspection  is 
made  of  the  vaginal  canal.  The  treatment  with  the  gal- 
vano-cautery  is  easy,  and  the  results  good.  A  free  incision 
is  made  with  the  cautery  knife  through  the  vaginal  wall, 
the  cyst  is  laid  open,  and  the  cyst  wall  cauterized  with  the 
knife  blade  applied  flatwise.  The  healing  is  accomplished 
in  less  time  than  when  the  incision  is  made  with  the 
knife ;  the  bleeding  vessels  are  ligated,  and  caustic  is  used 
to  destroy  the  cyst  wall. 

Were  it  possible  to  remove  the  entire  cyst  intact  by  dis- 
section, and  to  close  the  wound  with  sutures,  that  would  be 
the  most  perfect  procedure. 


ELECTRO-CAUTERY  IX   TREATMENT  OF   PELVIC   ABSCESS.     89 
VARICOSE    VEINS    OF   THE   VULVA 

The  veins  about  the  vulva,  like  those  iu  other  portions 
of  the  body,  may  take  on  a  varicose  condition.  This  com- 
monly occurs  in  those  who  have  borne  children ;  and,  in- 
deed, pregnancy  appears  to  stand  in  a  causative  relation 
thereto,  although  cases  undoubtedly  do  occur  in  those  who 
have  never  been  pregnant. 

Causation. — Anything  wliich  obstructs  the  venous  cir- 
culation will,  by  increasing  the  intravenous  pressure, 
tend  to  produce  this  varicose  condition,  whether  it  be 
a  pregnant  uterus,  a  tumor,  or,  as  mentioned  by  Winckel, 
the  straining  at  stool,  in.  case  of  obstinate  constipa- 
tion. 

Sym2?tomatology. — A  patient  may  liave  well-marked  vari- 
cose veins  of  tlie  vulva,  and  yet  be  entirely  unaware  of  the 
fact.  Or  a  sense  of  heat  and  irritation  may  be  experienced 
of  so  disagreeable  a  nature  as  to  cause  her  to  consult  a  phy- 
sician, when  the  presence  of  varicose  veins  may  be  recog- 
nized. In  still  other  cases  tlie  enlars"ement  or  swellino;  is 
so  great  as  to  attract  her  attention,  thougli  other  symptoms 
may  be  absent. 

Physical  Signs. — Upon  examination,  in  slight  cases,  the 
varicose  condition  of  the  veins  is  observed,  and  the  swelling 
disappears  on  pressure,  but  returns  immediately  when  the 
pressure  is  removed.  However,  in  more  aggravated  cases, 
there  may  be  so  muck  tumefaction  of  the  labia  and  other 
parts  as  to  mask  this  peculiar  condition  of  the  veins.  Hol- 
den  describes  a  case  in  which  a  tumor  existed  as  large  as 
the  head  of  a  child. 

The  diagnosis  iu  these  cases  is  to  be  made  by  excluding 
other  affections,  such  as  hernia,  hsematocele,  cysts,  and  cellu- 
litis. 

Surgical  treatment  should  be  limited  to  cases  that  are 
suffering,  and  in  which  there  is  danger  of  rapture  from  the 
extreme  distention  of  the  veins.  Indeed,  the  only  operative 
treatment  advised  is  lia'ation  and  exsection  of  the  veins. 


90  ELECTRO-H^MOSTASIS  IN   OPERATIVE   SURGERY. 

This  has  not  been  veiy  satisfactory,  owing  to  very  slow 
recovery. 

The  method  of  operating  which  I  have  adopted  is  as 
follows : 

An  incision  is  made  through  the  skin  over  the  raost 
prominent  part  of  the  mass  of  veins.  The  skin  and  sub- 
cutaneous tissues  are  separated  from  the  vessels  with  the 
scissors  or  dry  dissector,  until  the  parts  to  be  removed  can 
be  drawn  out  of  the  wound.  Then  when  possible  the  cen- 
tral portion  of  the  mass  is  dissected  out,  leaving  the  veins 
attached  above  and  below ;  the  upper  end  of  the  veins  is 
grasped  with  the  forceps,  com23ressed  and  heated  until  they 
are  closed  firmly.  The  lower  end  of  the  veins  should  be 
treated  in  the  same  manner,  and  the  whole  mass  cut  away. 
Any  small  vessels  in  the  wound  that  bleed  should  be  closed 
with  the  haemostatic  force^^s,  and  the  w^ound  closed  with 
sutui^es.  While  the  haemostatic  forceps  is  being  used,  the 
shield  forceps  should  be  placed  underneath  to  protect  the 
tissues  fi'om  the  heat  in  the  way  described  in  treating  the 
pedicle  of  an  ovarian  tumor. 

If  the  mass  of  distended  veins  is  not  very  large,  they 
can  all  be  seized  in  one  grasp  of  the  forceps,  and  treated  in 
one  piece  and  not  in  two  sections. 

This  method  of  operating  is  so  easily  carried  out,  and 
recoveiy  is  so  uneventful,  that  I  have  employed  it  in  cases 
of  lesser  degree  of  development.  I  have  the  impression 
that  the  method  might  be  employed  in  treating  varicose 
veins  of  the  leo-s. 

Contused  Wounds  of  the  Pudendum, — These  are  of 
two  degrees  of  severity.  A  slight  bruise,  causing  rupture 
of  only  a  few  small  vessels  (which  very  soon  stop  bleeding), 
gives  rise  to  an  ecchymosis,  which  quickly  disappears.  Oc- 
casionally inflammation  follows,  and  an  abscess  develops, 
which  is  managed  in  the  usual  way.  More  severe  are  con- 
tused wounds  which  rupture  the  large  vessels  of  the  bulbi 
vestibulares  or  existing  varicose  veins  of  the  labia,  and  pro- 
duce pudendal  htematocele — i.  e.,  an  accumulation  of  blood 


ELECTRO-CAUTERY  IN  TREATMENT  OF   PELVIC  ABSCESS.     91 

in  the  loose  cellular  tissue  of  the  parts.  The  pathology  of 
this  injury  is  the  same  as  that  of  bruises  or  contused  wounds 
generally.  There  are  laceration  of  the  vessels  and  hasmor- 
rhao'e  into  the  cellular  tissue. 

In  contusion  of  the  pudendum  two  conditions  conspii'e 
to  make  the  injuiy  grave  in  character — the  large  size  of 
the  vessels  wounded,  and  the  loose  character  of  the  cellular 
tissue,  ^vhich  admits  of  a  very  large  accumulation  of  blood. 
The  size  of  the  hsematoma  depends  upon  the  size  of  the 
vessels  lacerated.  In  case  the  vessel  is  small,  the  bleeding 
may  be  controlled  by  the  ]3ressure  from  the  blood  in  the  tis- 
sues ;  but  when  large  varicose  vessels  or  the  vessels  of  the 
bulb  of  the  vestibule  are  lacerated,  the  size  of  the  hsemato- 
cele  is  very  great.  I  have  seen  one  nearly  as  large  as  the 
two  fists. 

The  course  and  teiinination  of  the  haematocele  vary.  If 
the  blood-clot  is  small  it  may  disappear  by  absorption  with- 
out causing  much  discomfort,  after  the  first  pain  of  the 
injury  subsides ;  but  when  the  accumulation  of  blood  is 
large,  then  inflammation  follows  which  may  terminate  in 
sloughing  or  suppuration,  and  finally  septicaemia, 

Sijmpomatologij. — The  symptoms  are  pain  following 
the  injury,  and  then  a  feeling  of  fullness,  heat,  and  some- 
times throbbing.  In  one  case  that  came  under  my  observa- 
tion the  pressure  was  sufficient  to  prevent  urination,  and  it 
was  very  difficult  to  pass  the  catheter.  The  attention  of 
the  patient  being  directed  by  the  pain  to  the  location  of 
the  injury,  she  discovers  the  swelling  by  the  touch. 

Fhysiccd  /%n.s.— The  physical  signs  vaiy  in  the  differ- 
ent stao-es  of  the  disease.  At  first  the  tumor  is  elastic  and 
like  a  local  oedema,  except  that  it  does  not  pit  on  pressure. 
After  the  blood  has  coagulated  the  parts  are  denser  and 
slightly  irregular  or  slightly  nodular ;  discoloration  of  the 
skin  occurs  in  twenty-four  hours,  or  less.  (Edema  of  the 
skin  also  occurs. 

Diagnosis. — In  regard  to  the  diagnosis,  it  may  be  said 
that  pudendal  hsematocele  can  hardly  be  confounded  with 


92  ELECTRO-H^MOSTASIS  IX   OPERATIVE   SURGERY. 

any  of  the  diseases  of  the  pudendum  except  pudendal  liemia ; 
but  tlie  mode  of  development  and  physical  signs  of  the  two 
affections  are  so  unlike  that  the  differentiation  is  easy. 

Causation. — The  causes  of  pudendal  hsematocele  are 
predisposing  and  exciting.  Varicose  conditions  of  the  ves- 
sels, degeneration  of  the  vessel  walls,  and  marked  engorge- 
ment from  any  cause  which  interrupts  the  venous  circula- 
tion, render  the  vessels  more  susceptible  to  rupture  when 
subjected  to  any  injuiy. 

Pregnancy  predisposes  to  rupture  of  the  jDudendal  ves- 
sels, and  labor  is  one  of  the  most  prominent  of  the  exciting 
causes,  but  the  present  discussion  of  this  affection  is  limited 
to  causes  occuriing  in  the  nonpueii^eral  state.  The  reader 
will  find  a  very  full  account  of  this  affection,  as  it  occurs  in 
labor,  in  a  monograph  by  Prof.  Fordyce  Barker. 

In  regard  to  the  exciting  causes  of  the  affection,  it  may 
be  said,  in  brief,  they  are  always  traumatic.  Difficult  labor, 
direct  blows,  are  the  usual  means  by  which  the  vessels  are 
ruptured ;  indirect  injuries — from  a  fall,  for  instance — might 
produce  rupture  of  the  pudendal  vessels,  but  I  have  not 
seen  any  case  in  which  the  injujy  was  caused  in  that  way. 

Treatment. — When  the  patient  is  seen  while  the  bleed- 
inp-  is  still  going  on,  a  free  incision  should  be  made  through 
the  skin  and  the  blood  pressed  out;  the  bleeding  vessels 
seized  singly  or  in  mass  with  the  haemostatic  forceps  and 
closed  by  the  pressure  and  heat.  The  wound  is  then  closed 
with  sutures. 

In  cases  of  longer  standing  in  which  a  hsematoma  has 
been  formed  by  the  coagulation  of  the  blood,  the  incision 
should  be  made  with  the  cautery  knife  and  the  blood-clot 
turned  out.  Since  the  cellular  tissue  is  infiltrated  with 
blood,  the  whole  coagulum  can  not  be  removed  without 
starting  bleeding.  Hence  it  is  necessary  to  control  the 
bleeding  vessels  in  the  way  described.  The  cavity  being 
thus  freed  from  blood-clots  and  the  bleeding  completely 
controlled,  it  should  be  packed  with  gauze  and  allowed  to 
heal  fi"om  l)el<)\v  uutward. 


ELECTRO-CAUTERY  IN  TREATMENT   OF  PELVIC  ABSCESS.     93 

I  have  operated  by  making  tlie  incision  witli  the  knife 
and  ligating  the  vessels,  and  am  able  to  compare  the  old 
method  ^vith  the  new.  The  advantages  are  all  with  the 
new  method  of  operating. 

CARBUNCLE 

All  surg-eons  ao-ree  that  free  incision  is  indicated  in  car- 
buncle,  but  they  admit  that  there  are  objections  to  the  use 
of  the  knife,  chief  among  them  being  the  loss  of  blood  that 
can  ill  be  spared  by  the  subjects  of  carbuncle,  for  they  are 
always  in  a  low  state  of  general  health. 

There  is,  in  my  opinion,  still  another  objection  of  equal 
imjDortance,  and  that  is  the  absorj)tion  of  septic  matter  from 
the  incised  wound,  which  causes  a  further,  and  often  dan- 
gerous deterioration  of  the  general  health. 

These  objections  are  met  and  the  dangers  avoided  by 
using  the  cautery  knife  in  making  the  incision.  It  is  desira- 
ble to  open  a  carbuncle  before  death  of  the  deeper  tissues 
takes  place.  At  this  stage  of  the  disease  one  fi^ee  incision 
through  the  skin,  extending  across  the  parts  involved,  is 
required.  When  the  skin  is  divided  the  tension  is  usually 
sufficient  to  throw  the  wound  open  so  that  the  incision  can 
be  continued  down  through  all  the  tissues  involved.  When 
the  carbuncle  is  large  and  induration  well  marked,  two  sub- 
cutaneous incisions  should  be  made  at  rio^ht  ano-les  to  the 
first.  Clean  gauze  should  be  placed  into  the  wound  to 
keep  it  open  and  permit  the  serum,  which  soon  begins  to 
ooze  fi'om  the  tissues,  to  escape.  There  is  no  haemorrhage 
if  the  incisions  are  made  slowly  and  with  a  knife  at  red 
heat  and  the  wound  surfaces  are  rendered  incapable  of 
absorption.  The  pressure  is  taken  off  the  blood-vessels, 
the  circulation  is  re-established,  and  necrosis  prevented. 
When  necrosis  has  taken  place  the  whole  of  the  dead  tissue 
should  be  exsected.  That  can  be  done  by  making  a  circular 
incision,  retracting  the  edges  of  the  incision  in  the  skin,  and 
with  the  cautery  knife  dissecting  out  all  the  necrosed  tissue. 
It  is  necessary  to  keep  within  the  line  of  demarcation  be- 


94  ELECTRO-HiEMOSTASIS  IN  OPERATIVE  SURGERY. 

tween  dead  and  living  tissue.  The  separation  of  tlie  core 
or  necrosed  tissue  can  be  quickly  done  because  the  tissues 
are  softened  and  bloodless.  If  by  chance  any  portion  of 
the  dead  tissue  is  left  it  can  be  easily  seized  and  cut  off. 
It  sometimes  happens  that  a  large  artery  spurts,  having 
been  too  quickly  severed  with  the  cautery  knife.  In  that 
case  it  should  be  seized  with  the  haemostatic  forceps  and 
closed.  A  gauze  packing  should  be  loosely  applied  and 
left  until  it  becomes  saturated  with  the  discharge. 

Before  the  thin  crust  of  charred  tissue  separates,  the 
healing  process  is  well  advanced,  so  that  an  ordinary  gauze 
dressing  is  all  that  is  required  to  complete  the  treatment. 


CHAPTEE  X 

ELECTEO-HJEMOSTASIS    IJS^   EXTIEPATIOlSr    OF   THE   MAMMAEY 
AND    LYilPHATIC    GLANDS 

I  coNTrNUED  to  use  tlie  ligature  for  controlling  the  haemor- 
rhage in  extirpation  of  the  mammary  gland  long  after  I  had 
given  it  up  in  all  my  other  surgical  work.  This  was  owing 
to  the  fact  that  the  classical  method  had  given  general  satis- 
faction. Occasionally  there  would  be  suppuration  and  de- 
layed healing,  but  such  imperfections  were  attributed  to 
some  surgical  sin  of  commission  or  omission  on  the  part  of 
the  operator  and  assistants.  Then  a  rigid  investigation 
would  be  made  in  order  to  discover  the  source  of  infection. 
Some  possible  cause  of  the  objectionable  effects  were  usually 
discovered,  but  in  no  case  was  the  ligature  found  guilty  or 
responsible,  excepting  on  one  occasion  when  there  was  cause 
for  a  suspicion  that  the  catgut  used  was  not  aseptic.  There 
was  no  reason  in  this  to  induce  me  to  give  up  the  ligature,  so 
I  continued  to  use  it  in  this  operation,  until  my  first  assistant 
said  that  he  had  forgotten  how  to  tie  a  ligature,  and,  what 
was  more  to  the  point,  the  fact  of  having  forgotten  to  pro- 
vide clean,  reliable  catgut  ligatures,  suggested  that  the 
haemostatic  forceps  should  be  used  in  the  extirpation  opera- 
tion then  on  hand.  Though  belie\dng  that  more  time  would 
be  required  to  operate  in  this  way,  there  was  no  apparent 
objection  to  trying.  The  operation  was  performed  accord- 
ingly and  proved  to  be  so  gratifying  that  I  have  followed 
this  method  ever  since.  Not  that  this  method  of  operating 
has  proved  to  be  so* much  superior  to  the  old  way,  but 
because  it  has  been  more  satisfactory  in  being  followed 

95 


96  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

by  less  pain  and  a  shorter  period  of  recoveiy,  and  saves  all 
the  trouble  and  time  of  obtaining  reliable  catgut  ligatures. 

There  are  so  many  ways  of  preparing  catgut  ligatures 
that  one  is  in  doubt  regarding  which  to  choose,  and  I  find 
that  many  surgeons  prefer  preparing  their  own,  or  to  have 
them  prepared  by  assistants,  rather  than  to  obtain  them 
fi'om  dealers  in  surgical  supplies.  This  involves  an  amount 
of  labor  and  trouble,  and  withal  a  feeling  of  doubt  which 
the  surgeon  would  gladly  escape,  I  am  sure.  Perhaps  this 
doubt  regarding  the  sterility  of  catgut  ligatures  is  personal, 
and  others  may  have  confidence  in  them  when  prepared  as 
they  direct  or  practice.  I  can  only  say  that,  not  having 
time  to  prepare  my  own  ligatures  myself,  I  always  have  a 
fear  that  they  may  be  imperfectly  treated  or  contaminated 
in  keeping.  Therefore  this  made  me  the  more  willing  to 
give  up  ligatures  in  removing  the  mammary  gland,  though, 
as  already  stated,  I  was  fearful  that  more  time  would  be 
required  to  control  the  bleeding  with  the  new  haemostatic. 
JVIy  opinion  on  that  subject  was  a  mistaken  one.  In  actual 
practice  I  saved  time. 

Operation. — The  incision  is  made  and  the  gland  and  sur- 
rounding adipose  tissue  exsected  in  the  usual  way.  As  the 
arteries  are  divided  the  assistant  catches  them  with  ordi- 
nary compression  forceps  to  temporarily  control  the  bleed- 
ing. When  the  whole  breast  is  removed  and  all  suspicious- 
looking  parts  of  the  fascia  and  muscle,  each  forceps  is 
removed  in  the  order  of  its  application  and  the  haemostatic 
forceps  applied  exactly  to  the  part  from  which  the  other 
forceps  has  been  removed ;  the  heat  is  turned  on  for  a  half 
■or  a  quarter  of  a  minute ;  the  assistant  holds  the  forceps 
while  the  heat  is  being  applied,  and  meanwhile  the  operator 
applies  the  haemostatic  forceps  to  another  artery  and  trans- 
fers the  current  from  one  forceps  to  another.  The  forceps 
is  left  on  for  a  time  after  the  current  is  discontinued.  This 
is  done  because  I  found  that  the  heat  in  the  forceps  was 
sufficient  to  continue  the  desiccating  for  some  time  after 
the  heat  supply  was  cut   oif.     It  will  be  seen  from  this 


EXTIRPATION   OF  THE  MAMMARY  AND  LYMPHATIC  GLANDS.       97 

account  tliat  two  or  three  arteries  can  be  under  treatment 
simultaneously  and  much  time  saved  thereby. 

In  looking  over  the  history  of  cases  I  find  one  of  extir- 
pation of  the  mammary  and  axillary  glands  performed  in 
half  an  hour,  and  another  in  forty  minutes.  This  compares 
very  favorably  ^\dth  operations  in  the  old  way  so  far  as 
time  is  concerned. 

In  extirpation  of  the  axillary  glands  for  cancer  con- 
nected with  disease  of  the  breast,  I  have  found  this  method 
of  controlling  haemorrhage  very  satisfactory. 

The  mammary  gland  is  first  removed,  then  the  incision 
is  continued  along  the  border  of  the  pectoralis  muscle ;  the 
glands  and  adipose  tissue  are  then  dissected  away  from  the 
skin  and  fascia.  Each  gland  is  isolated  with  the  dry  dis- 
sector and  fingers,  and  drawn  away  from  the  large  vessels 
and  nerves ;  in  other  words,  they  are  made  pedunculated. 
A  narrow-bladed  haemostatic  forceps  is  applied  between  the 
gland  and  the  vessels  and  nerves,  the  heat  used  long  enough 
to  close  the  vessels,  and  then  the  gland  is  cut  away.  By 
being  careful  in  separating  the  glands  from  the  vessels  in 
this  way  there  is  less  danger  of  injuring  the  vessels,  the 
large  veins  especially. 

The  results  that  follow  compare  favorably  with  those 
obtained  by  other  surgeons,  and  are  superior  in  several  re- 
spects to  those  obtained  in  my  own  practice  by  operating  in 
the  usual  way.  There  is  less  pain  and  the  healing  process 
is  completed  in  much  less  time.  This  can  be  best  illustrated 
by  the  following  notes  of  a  case  recently  treated :  The 
patient  was  operated  upon  years  ago  at  different  times  for 
laceration  of  the  cervix  uteri,  laceration  of  the  pelvic  floor, 
and  rectal  haemorrhoids ;  subsequently  one  of  her  ovaries 
was  removed  by  vaginal  section ;  last  of  all  her  right  breast 
was  extirpated  for  cancer.  Her  experience  certainly  quali- 
fied her  to  judge  of  pain  after  surgical  treatment.  Her 
testimony  regarding  the  last  oj)eration  was  that  she  had  no 
pain  whatsoever.  There  was  no  rise  in  temperature,  and 
the  pulse  after  her  recovery  from  the  anaesthetic  remained 


98  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

normal  throughout  her  convalescence.  Her  appetite  and 
nutrition  were  normal,  and  she  slept  well.  On  the  morning 
of  the  fourth  day  she  left  her  bed  and  was  about  her  room. 
The  sutures  were  removed  on  the  seventh  day,  all  of  them 
coming  away  dry  and  without  any  bleeding.  Two  drops  of 
clear  serum  escaped  from  the  track  of  one  suture  after  its 
removal ;  union  was  complete  and  perfect,  and  there  was  no 
swelling  or  induration  of  the  parts.  There  was  no  traction 
upon  the  edges  of  the  wound.  A  thin  layer  of  sterilized 
cotton  was  placed  over  the  chest  and  a  bandage  applied. 
This  dressing  was  removed  on  the  twelfth  day  and  was 
found  to  be  dry  and  clean.  At  that  time  the  process  of 
repair  was  complete.  There  was  no  tenderness  anywhere, 
the  skin  was  everywhere  movable  upon  the  thorax  to  a 
slight  extent,  and  the  arm  could  be  moved  in  every  way 
without  pain.  Such  perfect  healing  of  the  skin  incision 
and  between  the  skin  and  deeper  tissues  of  the  thoracic 
wall  I  have  never  known  to  take  place  in  so  short  a  time  when 
a  number  of  ligatures  were  used  to  control  the  bleeding. 

A  comparative  study  of  this  and  others  operated  on  in 
this  way  indicates  that  the  process  of  repair  is  simpler  and 
is  completed  in  less  time  than  in  cases  in  which  ligatures 
have  been  used,  and  have  to  be  disposed  of  by  absorption 
or  becoming  encysted.  Therein  the  clinical  phenomena  and 
the  laboratory  experiments  coincide,  and  prove  as  clearly 
as  need  be  that  the  use  of  the  haemostatic  forceps  has  just 
claims  upon  the  surgeon's  confidence  in  regard  to  the  repair 
of  wounds. 

Having  found  that  extirpation  of  the  breast  is  a  rather 
long  operation,  owing  to  the  time  required  to  arrest  the 
haemorrhage,  I  was  of  the  opinion  that  the  new  haemostatic 
would  prolong  the  operation  still  more  ;  but,  as  already 
hinted  at,  less  time  was  required  to  close  the  arteries  com- 
pletely and  leave  the  wound  so  dry  that  no  drainage  was 
required.  More  time  was  needed  to  close  the  large  vessels 
than  if  the  ligature  had  been  used,  but  the  small  vessels, 
ignored  by  some  operators,  which  I  always  take  pains  to 


EXTIRPATION  OF  THE  MAMMARY  AND  LYMPHATIC  GLANDS.       99 

stop,  were  managed  in  less  time,  so  that  a  complete  drying 
state  of  tlie  wound  was  obtained  in  as  little  or  even  less 
time  than  I  had  ever  employed  while  operating  in  the  old 
way.  This  may  be  made  clear  by  giving  an  illustrative 
case :  The  patient  had  carcinoma  involving  about  two 
thirds  of  the  left  mammary  gland.  The  tumor  was  not 
large ;  the  skin  was  not  perceptibly  involved,  but  the  axil- 
lary glands  were  very  large,  indurated,  and  matted  together, 
forming  one  irregular  mass  a  third  of  the  size  of  the  tumor 
in  the  breast.  I  do  not  remember  having  seen  the  axillary 
glands  so  extensively  involved  in  connection  with  so  moder- 
ate an  advancement  of  the  disease  in  the  breast. 

By  an  unexplained  omission  the  blood  had  not  been 
examined,  and  I  was  surprised  by  the  discovery,  during  the 
operation,  that  she  was  hsemorrhagic.  There  was  no  great 
vascularity  apparent,  and  I  was  not  expecting  any  trouble 
with  the  haemorrhage,  nor  were  the  principal  arteries  large, 
but  the  smallest  vessels  kept  on  bleeding  so  that  I  was 
obliged  to  close  them  after  the  removal  of  the  breast  and 
before  clearing  out  the  axillary  glands.  Troublesome 
haemorrhage  was  anticipated  in  removing  the  lymphatics  in 
the  axilla,  but  I  was  pleased  to  find  that  I  had  less  trouble 
than  was  expected.  Some  bleeding  was  avoided  by  not 
extending  the  incision  of  the  skin  as  far  upward  as  usual, 
and  there  being  no  adhesions  of  the  parts  to  the  muscles, 
there  was  no  bleeding  from  small  muscular  arteries  such  as 
were  so  troublesome  in  the  breast  part  of  the  ojDeration. 
The  main  arteries  were  treated  in  the  way  described  in  the 
first  operation  given,  and  the  small  ones  were  caught  in  the 
small  artery  forceps  (which  was  kept  heated  continuously) 
and  held  for  the  few  seconds  required  to  stop  them.  The 
small  arteries  in  exposed  muscles  and  in  the  skin  were  the 
most  difficult  to  manage;  still  they  were  all  closed  and 
the  wound  made  quite  dry,  far  more  so  than  I  could  have 
made  it  by  using  ligatures.  The  surface  of  the  wound  was 
freely  studded  with  the  stumps  of  closed  vessels,  but  was 
smooth  and  clean  compared  with  what  it  would  have  been 


100  ELECTRO-H^MOSTASTS   IX   OPERATIVE   SURGERY. 

if  I  had  used  ligatures.  How  long  it  would  have  taken  me 
to  operate  if  I  had  used  ligatures  I  do  not  know,  but  I  am 
very  sui'e  that  I  could  not  have  so  completely  arrested  the 
haemorrhage  in  a  bleeder  like  that  one  by  ligation,  and  I 
have  never  been  able  to  do  such  an  operation  in  less  than 
forty-five  minutes,  the  time  required  in  this  case. 

The  incision  in  the  skin  was  made  short  to  avoid 
haemorrhage  and  to  save  the  necessity  of  many  sutures,  the 
latter  giving  great  advantage,  because  needle  punctures- 
bleed  freely  in  such  patients.  Only  two  sutures  were  em- 
ployed, and  the  remaining  part  of  the  wound  closed  with 
adhesive  strips.  The  healing  was  without  interruption. 
There  was  no  suppuration  and  only  a  very  little  escape  of 
pinkish-colored  serum  dming  the  first  day  after  the  oper- 
ation. 

EXTIRPATIOlSr    OF    DISEASED   LYMPHATIC   GLAJSTDS 

The  affections  of  the  lymphatic  glands  characterized  by 
enlargement  that  call  for  extirpation  are  not  to  be  con- 
sidered here.  The  classical  method  of  exsection  gives  entire 
satisfaction  no  doubt,  but  in  scrofulous  and  tubercular  dis- 
ease of  the  glands  in  the  inflammatory  stage,  especially 
^vhen  there  is  suppuration,  much  more  gratifying  results 
can  be  obtained  by  operating  with  the  galvano-cautery. 
At  least,  such  has  been  my  exj^erience. 

The  method  of  operating  should  be  adapted  to  the  con- 
dition present  in  an  adenitis  in  the  first  stage — that  is,  be- 
fore suppuration  has  taken  place.  The  incision  is  made 
Avith  the  cautery  knife  through  the  skin,  and  the  adhesions 
of  the  gland  to  the  neighboring  parts  separated  by  dry  dis- 
section ;  vessels  that  are  large  enough  to  bleed  are  closed 
with  an  application  of  a  haemostatic  and  divided.  Very 
often  the  main  artery  which  supplies  the  gland  is  imbedded 
in  a  mass  of  exudate  and  cellular  tissue  from  which  it  can 
not  be  isolated.  In  that  case  the  whole  mass  should  be 
treated  with  the  haemostatic  forceps  and  the  gland  set  free 
by  dividing  the  desiccated  portion  of  tissue  containing  the 


EXTIEPATION   OF  THE  MAMMARY  AND  LYMPHATIC  GLANDS.     101 

vessels  and  nerves.  Small  bleeding  vessels  that  are  found 
should  be  closed,  and  any  exudate  or  products  of  inflamma- 
tion that  have  been  left  should  be  dissected  out  and  the 
cavity  loosely  packed  with  gauze  and  an  aseptic  dressing 
applied. 

At  the  end  of  twenty-four  hours  the  gauze  packing 
should  be  removed  and  the  wound  redressed.  It  is  not 
necessary  to  introduce  any  drain  afterward  at  the  second 
dressing,  unless  the  wound  is  very  deep ;  the  incision  in  the 
skin  having  been  made  with  the  cautery,  the  surface  wound 
will  not  heal  before  the  cavity  is  closed. 

Suppurating  cases  are  operated  by  first  opening  into  the 
abscess  with  the  cautery  knife  and  removing  the  gland  tis- 
sue and  inflammatory  products  wdth  a  curette,  thoroughly 
washing  out  the  cavity  and  drying  it,  and  then  superficially 
but  completely  cauterizing  the  surface ;  finally  packing  and 
dressing,  as  described  above. 

This  method  of  operating  in  suppurating  tubercular 
disease  of  the  glands  gives  superior  results,  as  indicated  by 
a  speedy  and  complete  recovery.  Making  the  incision  with 
the  cautery  knife  prevents  haemorrhage  and  reinfection,  and 
the  cauterization  of  the  cavity  surface  arrests  the  suppura- 
tive disease  so  that  recovery  promptly  takes  place,  instead 
of  continued  suppuration  and  extension  of  tubercular  infec- 
tion, which  so  frequently  follows  after  evacuation  by  curet- 
ting alone,  and  finally  the  scar  is  smaller  than  that  which 
follows  the  usual  way  of  operating. 


CHAPTEE   XI 

ELECTEO-H^MOSTASIS    IN    EXTIEPATIO^iT    OF   TIHMOES    OF   THE 

BLADDER 

Iisr  times  past  I  had  considerable  experience  in  tlie  treat- 
ment of  neoplasms  of  the  bladder,  according  to  the  methods 
given  by  the  best  surgical  authorities. 

Either  vaginal  or  suprapubic  cystotomy  was  performed, 
the  choice  between  the  two  avenues  of  approach  being  de- 
termined by  the  location  of  the  growth  to  be  removed. 
When  the  part  to  be  removed  was  reached,  it  was  cut  off 
with  the  scissors  or  removed  with  the  cm*ette,  and  the 
haemorrhage  stopped  by  ligation  of  the  vessels  or  the  appli- 
cation of  such  styptics  as  hot  water,  persulphate  of  iron,  or 
acetic  acid.  The  bladder  was  drained  until  healing  took 
place.  I  never  cured  a  case  in  this  way,  and  I  am  not  sure 
that  the  life  of  the  patients  was  prolonged  by  the  treat- 
ment. In  fact,  in  two  of  my  patients  life  was  probably 
shortened,  though  great  relief  was  given  by  the  treatment. 

With  such  discouraoina:  results  before  me  I  determined 
to  try  the  clamp  and  cautery  method  of  operating. 

The  first  removal  of  a  neoplasm,  supposed  to  be  malig- 
nant, from  the  bladder  with  the  clamp  and  cautery  was 
one  in  which  I  was  able  to  make  an  accurate  diagnosis  of  a 
tumor,  about  an  inch  and  a  half  in  diameter,  on  the  upper 
part  of  the  anterior  wall  of  the  bladder.  The  patient  had 
for  months  suffered  almost  continuously  from  hsematuria. 
I  made  a  vesico- vaginal  fistula  by  dividing  the  tissues  with 
the  knife  and  scissors  ;  then,  by  having  pressure  made  above 
the  pubes  and  raising  the  vaginal  wall,  brought  the  tumor 

103 


EXTIRPATIOX   OF  TUMORS   OF   THE   BLADDER.  103 

down  to  the  vaginal  fistula,  and  succeeded  in  drawing  it 
through  into  the  vagina,  and  with  it,  of  course,  a  portion  of 
the  anterior  wall  of  the  bladder.  I  clamped  the  base  of 
this  growth  with  the  forceps  and  then  cut  it  off  with  the 
cautery,  and,  applying  the  cautery  to  the  blades  of  the  for- 
cep,  desiccated  the  portion  within  the  grasp  of  the  forceps, 
most  of  which  was  normal  mucous  membrane  ;  the  forceps 
was  then  removed,  the  bladder  thoroughly  washed  out,  and 
the  vesico-vaginal  fistula  closed  with  silk  sutures.  The 
bladder  was  drained  with  a  retained  catheter  for  twenty- 
four  hours  after  the  operation,  and  then  catheterized  every 
four  hours  for  three  or  four  days.  The  patient  made  a 
complete  recovery.  Having  succeeded  so  well  with  the 
clamp  and  cautery,  I  was  led  quite  naturally  to  expect  that 
still  better  work  could  be  done  with  the  haemostatic  for- 
ceps ;  and-  soon  after  that  instrument  was  devised,  I  found 
an  opportunity  to  try  it,  and  it  came  quite  up  to  my  highest 
expectations. 

This,  in  brief,  is  the  story  of  the  evolution  of  the  present- 
time  operation  for  neoplasms  of  the  bladder. 

EXTIRPATIOlSr    OF    NEOPLASMS    OF   THE    BLADDER   THROUGH  A 
VESICO-VAGESTAL    FISTULA 

Sing^le  tumors  of  small  size  attached  to  the  bladder  wall 
at  any  point,  excepting  the  middle  of  the  posterior  wall, 
can  be  removed  through  a  vesico-vaginal  fistula,  and  it  is  the 
best  way  of  operating. 

The  patient  is  placed  in  the  Sims  position,  and  an  open- 
ing made  in  the  median  line  large  enough  to  permit  the 
tumor  to  pass  through.  The  vaginal  wall  is  pressed  up- 
ward with  a  long  forceps,  the  open  blades  of  which  are 
placed  against  the  edges  of  the  fistulous  opening.  An  as- 
sistant makes  pressure  over  the  hypogastric  space  to  crowd 
the  bladder  down  to  the  opening,  and  force  the  tumor  out 
into  the  vagina.  The  operator  holds  the  forceps  which  sup- 
ports the  vaginal  wall  in  his  left  hand,  and  aids  in  the  de- 
livery of  the  tumor  with  a  small  sponge  in  a  holder.     The 


104  ELECTRO-HiEMOSTASIS   IN  OPERATIVE   SURGERY. 

sponge  is  used  instead  of  the  traction  forceps  to  aid  in  the 
delivery  of  the  tumor,  as  the  tissues  are  always  friable,  and 
the  forceps  would  tear  them.  When  the  base  of  the  tumor 
is  thus  brought  into  view,  the  haemostatic  forceps  is  applied, 
and  a  thin  shield  adjusted  to  prevent  the  heat  from  injuring 
the  bladder  or  mucous  membrane,  and  also  keep  the  partial- 
ly inverted  bladder  from  getting  away  from  the  operator. 
It  is  better  to  include  a  portion  of  the  mucous  membrane 
of  the  bladder  in  the  haemostatic  forceps  than  to  run  the 
risk  of  letting  any  part  of  the  diseased  tissues  escape.  The 
heat  should  not  be  above  175°,  but  should  be  continued  for 
tw^o  minutes  and  a  half ;  and  very  little  traction  should  be 
made  on  the  forceps,  because  the  tissues  are  friable  and 
easily  torn  from  their  attachment  to  the  bladder  wall. 
When  such  a  mishap  occurs,  the  bleeding  should  be  con- 
trolled by  singeing  the  points  that  bleed  with  a  small  haemo- 
static and  closing  them,  or  a  cautery  below  red  heat  may 
be  used. 

The  tumor  is  cut  off  close  and  the  forceps  opened 
enough  to  loosen  their  hold,  and  the  stump  is  permitted  to 
escape  by  slipping  off  the  forceps  as  one  would  take  a  ring 
off  the  linger.  In  that  way  the  delicate  stump  is  not  torn. 
Formerly  I  washed  out  the  bladder  before  closing  it,  but 
that  is  not  necessary. 

The  opening  in  the  bladder  is  closed  with  silk  sutures, 
and  drained  for  a  day  or  two  with  a  catheter  of  soft  rub- 
ber. Fig.  67  shows  the  tumor  croAvded  out  through  the 
opening,  with  the  forceps  and  shield  in  place. 

The  Suprapubic  Operation. — Large  and  multiple  neo- 
plasms and  those  inhabiting  the  lateral  walls  and  base  of 
the  bladder  can  be  successfully  removed  only  through  the 
suprapubic  opening. 

In  addition  to  the  usual  preparation  for  the  operation 
the  bladder  should  be  thoroughly  washed  out  and  disin- 
fected, using  every  care  not  to  start  bleeding.  A  mild 
solution  of  acetic  acid  is  the  best,  as  it  is  a  good  styptic 
and  a  fair  disinfectant.     The  bladder  should  be  filled  but 


EXTIRPATION   OP   TUMORS   OF   THE  BLADDER. 


105 


not  be  distended  with  air  or  water,  and  kept  so  until  the 
opening  is  made.  Distention  invariably  causes  haemorrhage 
less  or  more,  and  complicates  the  operation. 

The  opening  should  be  made  as  large  as  possible ;  the 
edges  of  the  wound  held  apart  with  retractors,  and  the 
interior  illuminated  with  direct  or  refracted  light.  The 
bladder  is  emptied  with  the  catheter  and  then  sponged 
dry.  In  case  there  are  a  number  of  growths  situated  at 
different  parts  of  the  bladder  each  one  is  caught  at  its  base 
with  the  haemostatic  forceps,  treated,  and  cut  off.     Single 


Fig.  67. — Bladder  tumor  drawn  out  through  a  vaginal  incision.  The  haemostatic 
clamp  grasps  the  pedicle;  the  shield  forceps  is  shown  by  dotted  lines  beyond 
the  clamp.     The  jjatient  is  in  the  Sims's  posture. 

large  growths  with  broad  attachments  are  treated  in  sec- 
tions ;  that  is  to  say,  a  portion,  such  as  can  be  grasped  at 
once  with  the  forceps  and  treated,  and  then  another,  until 
the  whole  is  exsected.  Long  retractors  are  used  to  keep 
the  bladder  walls  away  from  the  hot  forceps  in  cases  where 
there  is  not  room  enough  to  use  the  shield  forceps  con- 
veniently.    Fig.  68  illustrates  this  part  of  the  operation. 

When  the  disease  has  involved  the   muscular  wall   of 
the  bladder  (a  condition  found  only  in  cancer)  the  entire 


106 


ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 


base  of  the  tumor,  including  the  bladder  wall,  should  be 
removed.  That  is  done  by  first  removing  the  tumor  which 
projects  above  the  surface,  then  seizing  the  stump  in  the 
middle,  and  by  traction  drawing  it  inward  and  upward 
until  the  haemostatic  forceps  can  be  applied  and  the  whole 


ric  i-^:^Si:^Ti;a^r^!ii 


L': 

Fi&.  68. — A  pedunculated  growth  of  the  bladder  clamped  by  the  haemosratic 
forceps ;  the  bladder  wall  is  protected  by  the  shield  forceps.  On  the  anterior 
bladder  wall  the  stump  of  a  previously  treated  tumor  is  shown. 

of  the  diseased  part  removed  ;  or,  if  that  can  not  be  done  at 
once,  it  can  be  done  in  sections.  This  radical  treatment  of 
advanced  cases  should  not  be  undertaken  if  the  disease 
involves  or  goes  close  to  the  ureters  or  urethra.  In  the 
majority  of  eases   the   bladder    should   be   drained   from 


EXTIRPATION  OF   TUMORS   OF   THE   BLADDER.  107 

above  until  healing  is  completed;  but  if  the  base  and 
fundus  are  normal  the  wound  may  be  closed  and  drainage 
made  with  the  catheter. 

The  stumps  are  thrown  off  in  course  of  the  healing, 
and  should  be  washed  out.  Any  scrap  of  dead  tissue  left 
would  form  a  nucleus  for  a  calculus. 

There  being  no  haemorrhage  in  operating  in  this  way, 
the  procedure  is  easily  accomplished  compared  with  the 
old  way. 

The  wounds  left  to  heal  are  very  small,  and  the  stumps 
being  glued  together,  as  it  were,  become  almost  completely 
healed  before  the  desiccated  portions  are  thrown  off.  It 
may  be  said  that  the  bases  from  which  the  tumors  were 
removed  heal  under  a  scab,  thus  avoiding  ulcerating  sur- 
faces that  are  slow  to  heal. 

By  removing  single  small  neoplasms  in  this  way  the 
opening  in  the  bladder  can  be  closed  immediately,  and  the 
treatment  completed  in  one  operation.  The  thoroughness 
of  the  operation  prevents  or  delays  the  recurrence  which 
followed  sooner  or  later  in  all  my  cases  treated  according 
to  other  methods.  The  following  case  selected  from  a 
number  illustrates  the  clinical  history  and  treatment  of 
this  class  of  affections: 

Mrs.  H.  H.  C.  came  under  observation  in  January,  1892, 
saying  that  for  some  little  time  past,  following  convales- 
cence from  a  severe  attack  of  la  grippe,  she  had  been  notic- 
ing blood  in  her  urine.  At  first  but  little  attention  was 
given  to  this  condition  for  she  never  suffered  any  pain ; 
but  during  the  past  six  months  she  became  aware  of  feel- 
ing easily  fatigued,  and  felt  that  she  was  "  running  down  "  : 
at  the  same  time  the  hsematuria  was  becoming  more  and 
more  pronounced,  until  for  the  six  weeks  prior  to  her  ad- 
mission the  urine  constantly  showed  the  presence  of  large 
amounts  of  blood. 

The  haemorrhages  were  at  once  controlled  by  irrigations 
with  acetic  acid  and  the  administration  of  instillations  of 
fifteen  drops  of  fluid  extract  of  hydrastis  canadensis  before 


108  ELECTRO-H^MOSTASIS  IN  OPERATIVE   SURGERY. 

meals.  In  a  few  days  a  tliorough  cystoscopic  examination 
could  be  made.  The  bleeding  was  traced  to  a  papillo- 
matous growtli  in  the  upper  left  lateral  quadrant  of  the 
bladder.  The  tumor  was  removed  on  January  28th,  by 
way  of  the  vagina,  with  the  clamp  and  cautery.  The 
fistula  was  closed  at  once. 

The  recovery  was  favorable.  Some  large  granules  of 
phosphates  were  found  in  the  urine  for  a  few  days  after 
the  operation.  When  the  sutures  were  removed  in  the 
following  week  the  fistula  had  closed,  except  a  small  open- 
ing of  the  mucous  membrane  of  the  vagina  in  the  lower 
angle.  This  w^as  obliterated  within  the  week,  and  the  pa- 
tient left  the  sanatorium  nine  days  later. 

In  the  fall  of  1894  the  patient  returned  with  a  history 
of  entire  relief  until  a  few  months  ago ;  but  that  now  her 
mine  again  shows  some  color  almost  constantly,  and  at 
times  is  decidedly  bloody.  She  has  been  well  otherwise 
except  for  a  severe  siege  of  typhoid  fever,  but  this  did  not 
seem  to  have  any  influence  upon  her  bladder.  She  is  free 
fi'om  pain,  retains  her  urine  the  usual  length  of  time,  and 
feels  just  as  she  did  at  the  time  of  the  previous  operation. 

The  cystoscope  shows  a  possible  return  of  the  neoplasm, 
but  the  area  is  darker  in  color  and  looks  more  like  a  deposit 
of  urine  salts  on  the  scar.  The  examination  was  not  entirely 
satisfactory,  as  there  had  been  bleeding  the  day  before ;  so 
the  bladder  was  irrigated  and  prepared  for  another  exam- 
ination. This  time  the  cystoscope  reveals  several  neoplasms 
near  the  fundus ;  they  are  smooth,  lobulated,  of  a  grayish 
color.  There  is  also  a  body  in  the  base  of  the  bladder, 
round  and  like  a  stone,  but  it  does  not  give  the  character- 
istic click  when  touched  with  the  sound.  When  the  blad- 
der was  opened  this  area  was  found  to  be  a  deposit  of 
urinary  salts  on  a  soft  papillomatous  base.  A  suprapubic 
cystotomy  was  done,  and  a  number  of  small  papillomatous 
tumors  removed  by  the  new  method.  The  patient  was  dis- 
charged after  an  uneventful  recovery. 

Six  years  after  the  first  operation  the  patient  once  more 


EXTIRPATION   OP  TUMORS   OF   THE  BLADDER.  109 

returns  for  relief.  But  this  tiuie  tlie  history  is  very  differ- 
ent. She  has  been  in  almost  constant  pain  for  a  year.  At 
times  there  would  be  a  temporary  amelioration  of  her  con- 
dition, but  for  the  greater  part  of  the  period  she  has  been 
most  at  ease  only  when  lying  on  her  back.  Micturition 
has  been  nonnal,  but  frequent,  and  at  times  would  be  pre- 
ceded, again  followed,  by  shai-p  spasmodic  pains.  The  his- 
tory is  meager  as  to  the  appearance  and  character  of  the 
urine.  It  is  thought  that  two  small  gravel  stones  were 
voided  in  the  fall  of  1895,  yet  the  diagnosis  of  calculus  was 
not  made  by  the  physician  in  charge.  The  case  was  treated 
as  simple  catarrhal  cystitis.  The  only  other  important  inci- 
dent observed  was  an  occasional  incontinence. 

A  vesical  calculus  was  discovered  at  once,  and  the  diag- 
nosis confirmed  February  15,  1898,  by  doing  a  vaginal 
cystotomy  and  removing  a  large  stone.  The  weight  is 
fifty-six  grammes ;  it  is  fifty -five  millimetres  long,  thirty-five 
millimetres  wide,  and  one  hundred  and  ten  millimetres  in 
transverse  circumference.  The  shape  is  that  of  a  slightly 
irregular  ovoid  flattened  at  one  of  the  poles,  and  is  fairly 
smooth.  On  section  only  a  few  lamellae  are  seen,  and  these 
are  toward  the  periphery.  The  nucleus  is  distinguished 
from  the  rest  only  by  being  imbedded  in  a  deeper  mass  of 
more  porous  matter.  Chemical  analysis  places  it  in  the 
class  defined  by  Hoffman  and  Ultzman  as  "  metamorphosed  " 
stones,  for  it  is  composed  of  earthy  phosphates  forming  a 
quite  homogeneous  and  porous  mass. 

Convalescence  was  rapid ;  there  was  no  return  of  the 
pain ;  and  the  urine  showed  a  rapid  decrease  in  crystalline 
deposit  and  the  usual  evidences  of  bladder  irritation  caused 
by  a  calculus.  The  wound  was  left  open  to  insure  perfect 
drainage  for  a  time.  It  would  have  closed  of  its  own  ac- 
cord had  it  not  been  for  a  prolapsus  of  a  portion  of  the 
mucous  membrane  into  the  lower  angle  of  the  opening. 

The  after-treatment  has  consisted  in  daily  irrigations, 
and  for  a  week  maintaining  continual  drainage  during  the 
night  by  catheter.     Within   a  fortnight   the    patient  was 


110  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

able  to  sit  up  several  hours  daily  without  any  discomfort 
or  any  return  of  her  former  ill  feeling  or  symptoms,  and 
about  a  month  after  the  operation  returned  to  her  home. 

The  interest  in  the  case  centers  largely  in  there  being 
no  recurrence  of  the  former  growths,  in  the  age  of  the  pa- 
tient (she  is  now  sixty-three  years  of  age),  in  the  size  of 
the  stone,  its  rapid  formation,  and  that  its  formation  was 
due  to  some  scrap  of  dead  tissue  that  remained  after  the 
second  operation. 

After  remaining  at  home  for  two  months,  during  which 
time  she  Avas  well  and  regained  her  strength,  she  returned, 
and  I  closed  the  small  fistulous  opening  that  remained. 
Before  operating  to  close  the  fistula  a  most  rigid  examina- 
tion of  the  bladder  was  made,  but  no  foreign  body  was 
found,  and  not  the  slightest  evidence  of  a  recurrence  of  the 
papillomatous  growths.  It  is  now  nearly  a  year  since  she 
went  fi'om  under  my  care,  and  she  is  perfectly  well  in 
every  respect. 

THE  TREATMENT  OF  ULCERS  OF  THE  BLADDER  WITH  THE 
GTALVANO-  CAUTERY 

I  was  induced  to  use  the  galvano-cautery  in  the  treat- 
ment of  ulcers  in  the  bladder  by  a  somewhat  curious  expe- 
rience. 

A  girl  nineteen  years  of  age  came  to  my  clinic  suf- 
fering from  hsematuria,  which  had  troubled  her  for  over 
two  months.  Her  health  was  good  and  the  urine  normal, 
excepting  the  blood  which  it  contained.  I  first  made  sure 
that  the  blood  came  from  the  bladder,  and  then  put  her 
upon  the  usual  internal  remedies  for  haemorrhage  of  the 
bladder,  but  with  no  benefit  to  her.  A  bimanual  examina- 
tion of  the  bladder  gave  negative  evidence,  but  it  increased 
the  haemorrhage  for  a  time.  A  solution  of  acetic  acid, 
which  was  used  to  wash  out  the  bladder,  controlled  the 
bleeding  long  enough  for  a  cystoscopic  examination.  On 
the  lower  part  of  the  posterior  wall  I  found  a  whitish-gray 
colored  body  about  three  eighths  of  an  inch  in  diameter, 


EXTIRPATION   OF   TUMORS   OF   THE  BLADDER.  m 

surrounded  by  a  border  of  papillomatous  or  granulation 
tissue  very  red  and  vascular.  A  diagnosis  of  calculus 
partially  encysted  was  made  upon  the  physical  signs  ob- 
tained with  the  cystoscope.  The  use  of  the  sound  and  a 
bimanual  examination  gave  no  evidence  confirmatory  of  the 
diagnosis.  The  bladder  was  opened  through  the  vagina, 
and  I  found  that  the  object  which  appeared  to  be  a  stone 
was  a  thick  deposit  of  urine  salts  upon  an  ulcerated  sur- 
face. The  deposit  and  soft  vascular  tissue  around  it  were 
removed  with  a  curette  and  pressure  made  upon  the  raw 
surface  with  a  sponge  until  the  bleeding  ceased.  A  small 
galvano-cautery  was  applied — at  dull  red  heat — to  the 
whole  surface  long  enough  to  destroy  the  whole  of  the 
diseased  tissue  and  form  a  thin  dry  crust  over  all. 

The  wound  in  the  vagina  was  closed,  and  the  bladder 
drained  with  a  catheter  for  three  days.  After  that  the 
patient  was  made  to  urinate  every  four  hours  for  the  re- 
mainder of  the  week.  About  that  time  a  number  of  black- 
ish particles  were  passed  with  the  urine — the  debris  of  the 
cauterized  tissue.  For  several  days  thereafter  the  bladder 
was  washed  out  to  make  sure  that  no  bits  of  dead  tissue 
remained  to  cause  the  formation  of  a  calculus. 

The  patient  made  a  good  recovery,  and  was  well  a  year 
later,  at  which  time  she  was  and  gave  promise  of  continu- 
ing free  from  recurrence  of  the  affection. 

The  benefit  derived  from  the  cautery  in  this  case  in- 
duced me  to  employ  the  same  treatment  in  cases  of  ulcera- 
tion of  the  bladder.  In  chronic  cystitis  of  long  standing, 
especially  in  aged  women,  an  ulceration  occasionally  occurs 
generally  at  the  base  of  the  bladder.  These  are  seldom 
cured  by  instillations  or  caustic  applications.  This  was 
another  inducement  to  try  the  cautery.  The  diagnosis  and 
the  localization  of  the  ulcer  is  made  with  the  cystoscope. 
The  operation  or  application  is  made  by  placing  the  patient 
in  the  knee-chest  position,  introducing  the  largest  endo- 
scope that  can  be  used  with  safety,  and  bringing  the  dis- 
eased part  into  the  field  of  vision  and  applying  the  cau- 


112  ELECTEO-HiEMOSTASIS  IN   OPERATIVE  SURaERY. 

tery.  Ulcers  of  considerable  size  can  not  be  all  seen  at 
once,  and  so  one  requires  to  cauterize  portions  at  a  time, 
doing  one  part  and  then  another  till  tlie  whole  is  treated. 
Considerable  experience  and  practice  is  necessary  in  order 
to  operate  successfully,  but  the  benefits  derived  compensate 
fully  for  all  that. 


CHAPTEE  XII 

THE   ELECTEO-CAUTEEY    IN    THE    TREATMENT    OF    URETHRAL 

AFFECTIONS 

The  diseases  of  the  urethra  in  which  the  electro-cautery 
is  most  eilective  are  neoplasms  about  the  meatus,  urethritis, 
narrowing  of  the  meatus,  either  congenital  or  acquired,  and 
inflammation  of  the  urethral  glands  and  follicles. 

In  regard  to  the  pathology  of  these  neoplasms  at  the 
meatus  urinarius,  there  are  two  forms  to  which  I  wish  to 
call  attention.  One,  the  rarest,  is  angioma^  caused  usually 
by  malnutrition  and  deranged  circulation.  These  growths 
closely  resemble  rectal  haemorrhoids  in  both  the  pathology 
and  the  causes  which  produce  them.  The  other  is  a  pro- 
liferation of  tissue,  caused  by  a  chronic  inflammation  of  the 
glands  or  follicles  in  the  vaginal  side  of  the  urethra. 
Both  varieties  have  been  known  as  vascular  growths  of  the 
meatus  or  caruncle. 

The  diagnosis  is  of  course  easily  made  when  the  dis- 
ease is  confined  to  the  exposed  portion  of  the  meatus,  but 
when  these  growths  are  within  the  urethra  the  diagnosis 
can  be  made  only  by  the  use  of  the  endoscope.  I  may 
state  in  passing  that  many  do  not  use  this  instrument  for 
diagnostic  purposes,  owing  to  its  being  rather  inconvenient 
and  requiring  experience  in  its  use.  To  meet  that,  I  find 
in  many  cases  a  diagnosis  can  be  made  by  exclusion.  Dis- 
placements and  dislocations  can  be  detected  or  excluded  by 
the  touch  and  sound,  and  cystitis  can  be  disposed  of  by  fre- 
quent and  careful  urine  examinations. 

Most  important  of  all  in  this  connection  is  the  cysto- 
us 


114  ELECTRO-H^MOSTASIS  IN   OPERATIVE  SURGERY, 

scope,  wliicli  is  so  valuable  in  detecting  or  excluding  dis- 
eases of  the  bladder  wliicli  simulate  in  a  marked  way  cer- 
tain diseases  of  the  urethra,  but  this  instrument  is  not 
always  at  command.  I  find  that  the  differential  diagnosis 
must  be  made  by  the  majority  of  practitioners,  if  made  at 
all,  by  examinations  of  the  urine  and  from  the  symptoms. 
When  it  is  determined  by  exclusion  that  the  disease  is  con- 
fined to  the  urethra,  the  question  rests  then  between  inflam- 
matory affections  and  displacements  and  dilatation.  The 
latter  can  be  detected,  as  before  stated,  by  the  touch  and 
sound. 

To  return  to  the  treatment  of  neoplasms,  the  indications 
are  to  thoroughly  and  completely  destroy  the  diseased  tis- 
sue and  nothing  more.  To  do  this  with  caustics  in  the  way 
usually  commended  is  impossible — at  least  I  find  it  so. 
The  diseased  tissue  can  be  destroyed,  if  not  by  one,  by 
several  applications ;  but  the  line  of  demarcation  between 
the  normal  and  abnormal  tissue  can  not  be  clearly  and  accu- 
rately drawn,  and  the  action  of  the  caustic  limited  to  that 
one  part.  After  the  eschar  separates  the  surface  left  to 
heal  is  large,  painful,  and  tender,  and  during  the  healing 
process  there  is  great  liability  to  the  recuiTence  of  the  orig- 
inal disease.  This  is  one  of  the  reasons  for  the  frequency 
with  which  these  growths  return,  as  noted  by  all  writers  on 
the  subject.  Exsection  is  a  more  surgical  method  which 
gives  better  results  when  well  done  than  caustics ;  but  un- 
less sutures  are  used  to  close  the  wound  the  healing  is  slow 
and  uncertain,  especially  if  the  urine  is  in  any  degree 
morbid. 

The  galvano-cautery  fulfills  all  the  requirements  per- 
fectly and  completely.  There  is  less  pain  in  its  use.  Heal- 
ing is  more  rapid,  and  there  is  less  likelihood  of  the  disease 
returning. 

The  cautery  instrument  which  I  employ  is  the  fine  point. 
(See  Fig.  75.) 

A  larger  cautery  can  be  used  with  advantage  in  remov- 
ing large  neoplasms,  but  for  all  general  purposes  the  small 


TREATMENT  OF  URETHRAL  AFFECTIONS.        II5 

one  is  the  best.  I  may  here  mention  the  fact  that  it  should 
be  brought  to  the  desired  heat  before  applying  it  to  the 
tissues,  and  then  after  making  one  incision  or  application  it 
should  be  withdrawn  from  the  tissues  and  reheated.  This 
is  necessary,  because  the  moment  this  fine  point  is  brought 
into  contact  with  the  tissues  there  is  so  much  leakag'e  of 
the  current  that  the  cautery  very  soon  cools  off  a  little.  I 
mention  this  because  I  have  so  often  seen  the  inexperienced, 
who  were  not  aware  of  this  fact,  bothered  by  the  cautery 
cooling  and  not  doing  its  work  fast  enough. 

The  method  of  ojoerating  for  angioma  at  the  meatus 
urinarius  is  as  follows  : 

The  neoplasm  to  be  removed  is  seized  by  narrow-bladed 
forceps  at  the  junction  of  the  normal  and  abnormal  tissue ; 
the  forceps  is  closed  and  locked  and  the  neoplasm  cut  off. 
The  current  is  turned  on  and  continued  to  heat  the  forceps 
enough  to  desiccate,  not  char,  the  tissues  in  its  grasp.  When 
this  is  accomplished  the  forceps  is  carefully  removed  by 
first  unlocking  it,  then  rocking  it  gently,  so  as  not  to  pull 
the  pedicle  or  stump  apart  and  start  bleeding.  If  the  work 
is  well  done,  the  thin  stump  of  desiccated  tissue  will  pro- 
ject from  the  surface  of  the  mucous  membrane.  If  there 
is  any  portion  of  the  diseased  tissue  left,  it  should  be 
touched  with  the  cautery. 

It  is  important  that  the  patient  should  not  urinate  for 
several  hours  after  the  operation,  because  if  the  stump  can 
be  kept  dry  for  a  time  it  will  not  spread  but  hold  together, 
and  leave  a  very  small  surface  to  heal  when  the  desiccated 
portion  separates.  The  application  of  stearate  of  zinc  helps 
to  protect  the  stump  until  it  heals. 

The  forceps  which  I  use  is  like  the  compression  forceps 
but  with  very  narrow  blades. 

This  method  of  operating  is  sufficient  in  the  ordinary 
forms  of  angioma.  When  the  neoplasm  is  caused  by  a 
chronic  inflammation  of  the  urethral  glands,  the  best  method 
is  to  pass  a  fine  probe  uj)  into  the  canal  and  cut  down  upon 
it  with  the  cautery  point  from  the  vaginal  surface  ;  in  other 


116 


ELECTRO-HJEMOSTASIS  IN  OPERATIVE  SURGERY. 


words,  lay  the  ducts  of  the  glands  open.  This  divides  the 
neoplasm  on  one  side,  and  an  incision  should  be  made  with 
the  cautery  on  the  opposite  side,  which  divides  the  neo- 


FiG.  69. — Operation  upon  diseased  urethral  giands.  A  fine  probe  is  passed  into 
the  gland ;  the  tissue  is  rendered  tense ;  the  knife  is  about  to  cut  down  upon 
the  probe. 

plasm  into  two  equal  parts ;  then  each  part  is  grasped  in 
the  forceps  and  removed  in  the  way  I  described  in  the 
treatment  of  angioma.  The  method  of  treating  the  disease 
of  the  urethral  glands  is  illustrated  by  Figs.  69  and  70. 

I  have  succeeded  in  completely  curing  the  chronic  in- 
flammation of  the  glands  by  laying  their  ducts  open  in  this 
way  and  removing  the  neoplasms  at  their  terminal  ends, 
excepting  in  a  few  cases  where  the  inflammation  still  per- 
sists in  the  glands.  To  correct  this  I  generally  do  a  second 
operation.  I  pass  the  cautery  point  into  the  gland  and 
cauterize  it  sufficiently  to  destroy  it.     I  have  succeeded  in 


TREATMENT  OF  URETHEAL  AFFECTIONS. 


iir 


curing  all  cases  in  this  way,  except  in  tuberculosis  of  the 
urethra.  That  disease  has  continued  when  the  upper  por- 
tion of  the  canal  was  involved  before  operating. 

The  method  of  operating  in  cases  of  narrowing  of  the 
meatus  urinarius  is  this :  I  pass  a  bivalve  speculum  into 
the  urethra  and  put  the  meatus  on  the  stretch.  The  band 
of  tissue  below  or  on  the  vaginal  side  which  extends  from 
one  blade  to  the  other  is  made  tense,  and  is  easily  divided 
with  the  cautery ;  in  fact,  it  is  necessary  to  be  deliberate  in 
making  the  incision,  or  else  haemorrhage  will  follow ;  not  a 
hgemorrhage  which  will  give  any  trouble  except  delay,  as  it 
prevents  continuing  the  use  of  the  cautery  to  complete  the 
operation. 

In  cases  of  papillae  within  the  urethra,  caused  by  hyper- 


FiG.  70. — The  incision  gapes  after  splitting  open  the  gland. 

plasia  around  the  follicles,  the  treatment  with  the  cautery 
is  difficult,  but  if  properly  employed  gives  the  most  prompt 
relief  in  those  cases  of  chronic  inflammation  which  have 
been  called  o-ranular  urethritis.     After  havino;  made  a  clear 


118  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

diagnosis  and  localized  tlie  points  to  be  destroyed,  I  intro- 
duce the  endoscope  with  an  open  end,  up  as  near  to  the 
neck  of  the  bladder  as  can  be  without  permitting  a  flow  of 
urine ;  the  instrument  is  then  withdrawn  until  one  of  the 
points  to  be  touched  comes  into  the  field  of  vision;  the 
cautery  is  then  passed  up,  and  the  point  slowly  touched 
once,  which  is,  as  a  rule,  sufiicient.  The  endoscope  is  then 
again  withdrawn  until  another  diseased  portion  appears, 
which  is  treated  in  the  same  way,  and  so  on  until  the  treat- 
ment is  completed. 

IRRITABLE  ULCER  OF  THE  NECK  OE  THE  BLADDER 

The  most  troublesome  of  all  diseases  of  the  urinary 
organs,  both  in  the  way  of  causing  suffering  to  the  patient 
and  botheration  to  the  surgeon,  is  this  ulcer  or  fissure  at 
the  junction  of  the  urethra  and  bladder. 

The  first  difficulty  is  in  making  a  diagnosis.  In  fact,  I 
have  never  been  able  to  fully  expose  a  fissure  in  the  loca- 
tion except  with  the  glass  endoscope,  and  I  have  tried  all 
other  instruments  in  use.  The  treatment  also  is  difficult. 
When  the  fissure  is  exposed  by  means  of  an  endoscope  open 
at  the  distal  end  there  is  a  continual  oozing  of  urine,  which 
interferes  with  the  use  of  the  cautery.  If  the  fissure  is  on 
the  vaginal  side  of  the  urethra,  this  is  obviated  by  using  a 
fenestrated  endoscope  and  bringing  the  fissure  into  the  field 
of  vision,  while  making  pressure  against  the  endoscope  from 
the  vagina  with  the  finger,  to  force  the  diseased  portion  of 
the  mucous  membrane  into  the  fenestrum  and  prevent  the 
outflow  of  urine.  I  then  dry  the  part  with  a  small  piece  of 
bibulous  paper,  and  apply  the  cautery  by  simply  drawing 
the  point  slowly  through  the  ulcer  so  as  to  completely 
destroy  its  surface. 

To  a  certain  extent  lateral  fissures  can  be  managed  in 
the  same  way,  but  when  the  fissure  occurs  above,  which 
fortunately  seldom  happens,  it  is  almost  impossible  to  em- 
ploy this  treatment.  Perhaps  when  I  have  had  more  ex- 
perience I  may  be  able  to  report  quite  favorably  of  this 


TREATMENT  OF  URETHRAL  AFFECTIONS.        119 

treatment.  Up  to  the  present  time  it  is  not  completely  sat- 
isfactory, though  the  best  that  has  been  obtained  so  far  in 
treating  those  forms  of  urethral  affections  already  alluded  to. 
I  find  that  with  the  use  of  cocaine  general  anaesthesia  is 
not  necessary,  at  least  in  patients  who  possess  a  fair  degree 
of  self-control,  but  I  should  advise  the  use  of  an  anaesthetic 
until  the  surgeon  has  acquired  some  skill  and  dexterity  in 
the  management  of  the  endoscope  and  the  cautery. 


CHAPTEE  XIII 

ELECTRO-H^MOSTASIS    IIST    THE    TREATMENT    OF    EECTAL 
H^MOEEHOIDS 

The  clamp  and  cautery  was  used  for  a  long  time  in 
operating  for  hsemorrhoids,  but  tlie  results  obtained  were 
not  altogether  satisfactory.  The  clamp  spread  out  the 
tissues  so  that  a  broad  stump  was  formed,  and  after  re- 
moving the  clamp  the  tissue  of  the  stump  separated,  leaving 
a  broad  surface  to  heal.  Bleeding  was  often  caused  by  the 
action  of  the  bowels  unless  confined  for  a  long  time,  and 
healing  was  retarded. 

These  unfavorable  conditions  were  avoided  to  some 
extent  by  using  a  clamp  with  broad  Jaws,  and  after  cutting 
off  the  hsemorrhoid,  applying  the  cautery  to  the  forceps 
long  enough  to  desiccate  the  stump  in  the  way  that  Keith 
treated  the  pedicle  of  ovarian  tumors.  This  required  alto- 
gether too  much  time,  and  it  was  so  difficult  to  avoid  too 
much  or  too  little  heat  that  I  became  discouraged  and  re- 
turned to  the  ligature  until  the  introduction  of  the  haemo- 
static forceps.  Since  then  I  have  adopted  that  method, 
and  practice  it  exclusively. 

In  the  preparatory  treatment  plenty  of  time  should  be 
taken  to  get  the  digestive  organs  into  the  best  possible 
condition.  If  the  tongue  is  coated  and  the  appetite  im- 
paired, small  doses  of  mild  chloride  of  mercury  should  be 
given,  followed  by  a  cathartic.  A  laxative  should  be  given 
in  the  evening  before  the  day  preceding  the  operation,  so 
that  the  bowels  shall  move  in  the  morning,  and  at  night 

120 


TREATMENT  OF  RECTAL  HEMORRHOIDS.  121 

before   tlie   operation  tlie  rectum   should  be  washed  out 
thoroughly. 

The  sphincter  is  slowly  stretched  with  a  bivalve  spec- 
ulum to  a  degree  sufficient  to  temporarily  paralyze  the 
muscle,  but  not  to  tear  its  fibers  or  lacerate  the  hgemor- 
rhoidal  veins  if  possible.  The  most  prominent  hsemorrhoid 
tumor  is  caught  with  a  Pean  forceps  and  drawn  outward 
(see  Fig.  72,  A),  the  hj^morrhoidal  clamp  is  applied  to  its 
base,  and  the  electric  heat  continued  until  desiccation  is  com- 
plete ;  this  requires  from  half  a  minute  to  a  minute,  rarely 
more  than  half  a  minute,  unless  the  tissues  are  very  large. 
A  shield  forceps  with   shields  of  horn,  tortoise  shell  or 


Pig.  71. — Haemostatic  haeraorrhoidal  clamp. 

ivory,  similar  to  the  shield  forceps  used  in  ovariotomy,  is 
placed  under  the  clamp  to  protect  the  tissues  while  the  heat 
is  being  applied. 

The  clamp  (see  Fig.  71)  is  made  on  the  same  prin- 
ciple as  the  ovariotomy  clamp  described  in  the  chapter  on 
ovariotomy,  but  is  much  smaller. 

Fig.  72,  I^,  shows  the  clamp  in  place  parallel  to  the 
axis  of  the  canal  while  the  current  is  being  used. 

Fig.  73  shows  the  clamp  opened  just  enough  to  per- 
mit the  stump  to  escape  from  its  grasp. 

Fig.  72,  C,  shows  the  stump  after  treatment;   the  long 


122 


ELECTEO-H^MOSTASIS  IX  OPERATIVE   SURGERY. 


measurement  is  in  tlie  axis  of  tlie  canal,  as  it  should  be,  in 
order  that  it  may  rest  in  the  folds  of  the  mucous  membrane 
when  the  sphincter  contracts. 

During  the  process  of  repair  the  stump  becomes  soft- 
ened by  absorption  of  moisture,  and  part  of  it,  at  least, 
separates  and  comes  away,  but  not  until  the  base  has  com- 
pletely healed.  The  reader  will  observe  that  a  stump  ex- 
posed on  a  fi'ee  surface  is  not  reorganized  as  is  a  stump 
inclosed  in  the  abdominal  cavity  or  in  cellular  tissue.  It 
appears  that  the  portion  of  the  dried  stump  joining  the  liv- 


PiG.  72. — A,  the  hEemorrhoid  is  drawn  outward  by  a  forceps ;  B.  the  haemostatic 
clamp  and  shield  forceps  in  position  while  the  current  is  being  used ;  C,  the 
stump  after  treatment ;  the  long  measurement  is  in  the  axis  of  the  canal. 

ing  tissue  may  become  organized  during  healing,  but  the  free 
end  separates    and  is  thrown   off  as   stated    above.     The 


TREATMENT   OF  RECTAL  HEMORRHOIDS. 


123 


mucous  membrane  remains  tender  at  the  site  of  operation 
until  the  process  of  repair  is  complete,  therefore  the  parts 


Fig.  73. — The  clamp  has  been  opened  to  permit  the  stump  to  escape  from  its  grasp. 


are  easily  torn  open  by  distending  the  sphincter  out  to  any 
great  extreme.  On  that  account  the  bowels  should  be  kept 
at  rest  for  several  days  after  operation. 

Owing  to  the  stump  in  its  greatest  length  running  par- 
allel to  the  axis  of  the  rectum,  it  is  in  the  position  most 
exposed  to  being  opened  up  when  the  bowels  are  evacuated. 

Dr.  E,.  L.  Dickinson  suggested  that  the  danger  of  open- 
ing up  the  stumps  might  be  guarded  against  by  applying 
the  clamp  at  right  angles  to  the  axis  of  the  rectum,  or 
rather  he  suggested  that  it  should  be  made  obliquely.  (See 
Fig.  74.)  The  effect  of  distending  the  sphincter  would  be 
to  draw  the  edges  or  sides  of  the  stump  more  closely  to- 
gether, not  to  pull  them  apart.  This  appeared  to  me  to  be 
a  valuable  suggestion,  and  I  shall  try  it,  taking  care  to  have 
the  stumps  all  outside  of  the  grasp  of  the  sphincter  when 
the  location  of  the  hsemorrhoid  is   such  that  this  can  be 


124 


ELECTRO-H.EMOSTASIS  IN  OPERATIVE   SUROERY. 


done.  That  is  to  say,  I  shall  form  the  stump  at  the  junc- 
tion of  the  skin  and  mucous  membrane. 

After-treatment. — The  parts  are  dusted  with  dry,  finely 
powdered  bicarbonate  of  soda  or  subgallate  of  bismuth, 
applied  with  the  insufflator. 

The  patient  is  kept  at  rest  for  a  week  or  ten  days,  and 
liquid  diet  given — soups,  broths,  and  gruels  being  preferable 
to  milk. 

As  this  operation  is  followed  by  much  less  pain  than 
when  the  ligature  is  used,  opium  is  seldom  required.    When 


Fig.  74. — Diagrams  of  sears  or  stumps  after  removal  of  piles,  and  the  strains  ap- 
plied to  those  lines  of  union.  A,  ordinary  seizure  of  forceps  in  removing  pile. 
The  tip  of  the  clamp  pointing  directly  in  long  axis  of  anus,  three  bites  being 
sketched,  the  edges  of  the  mucous  membrane  of  the  upper  one  having  pulled 
apart  as  rectal  plug  is  withdrawn  or  fasces  pass,  leaving  a  fissure  to  granulate; 
B,  oblique  bite  here  advocated  as  least  likely  to  be  dragged  open;  C,  "White- 
head operation  partly  sutured,  circular  line  of  union.  The  stresses  are  two — 
longitudinal,  in  the  axis  of  the  anus ;  and  transverse,  at  right  angles  to  that 
axis.  The  longitudinal  stress,  shown  by  the  stumpy  arrows,  and  produced  by 
the  shoving  onward  of  the  mucous  membrane  or  skin  about  the  anus  as  a 
faecal  mass  makes  exit,  can  have  little  hurtful  effect  on  A,  and  much  on  C. 
The  transverse  tension,  produced  by  stretching  of  sphincter  by  fa?cal  mass, 
shown  by  the  longer  curved  arrows,  does  no  harm  to  C,  but  great  hurt  to  A. 
The  oblique  bite,  B,  is  least  likely  to  be  hurt  by  the  combined  strain. — Brook- 
lyn Medical  Journal,  vol.  xiii.  No.  1,  p.  54,  January,  1899. 

called  for,  I  use  liquor  opii  comp.  and  tincture  of  belladonna, 
instilled  into  the  rectum  with  a  soft  catheter  or  pipette. 
The  bowels  can  be  safely  moved  on  the  second  or  third  day, 
but  it  is  better  to  keep  the  patient  on  spare  liquid  diet, 
and  wait  until  the  fourth  or  fifth  day.  On  the  evening  of 
the  fourth  day  a  small  laxative  dose  of  pulve.  glycerrhiza 
comp.  is  given,  and  followed  in  the  morning  with  a  dose  of 
phosphate  of  soda  and  two  hours  later  an  enema  of  flax- 


TREATMENT  OF   RECTAL   HEMORRHOIDS.  125 

seed  tea.  The  flaxseed  tea  is  the  most  agreeable  and  efficient 
enema  in  all  rectal  diseases  when  this  aid  to  action  is  re- 
Cjuired.  iVfter  the  bowels  are  evacuated  the  parts  should  be 
thoroughly  cleansed  by  irrigation,  then  dried  with  absorb- 
ent cotton,  and  the  subgallate  of  bismuth  powder  employed. 
The  bowels  are  pemiitted  to  rest  for  one  day,  and  after  that 
they  should  be  moved  each  day.  Some  of  the  best  author- 
ities permit  their  patients  to  sit  up  in  about  three  days, 
and  in  about  a  week  they  are  allowed  to  go  about ;  but  I 
am  sure  that  this  is  not  the  best  after-care.  It  is  better  to 
keep  the  patient  quiet  until  healing  is  complete,  which  re- 
quires about  ten  or  twelve  days.  It  is  claimed  that  pa- 
tients treated  in  the  old  way  are  able  to  be  up  and  at  busi- 
ness in  a  few  days,  but  better  results  are  obtained  by  taking 
more  time. 

Finally,  comj^lete  recovery  takes  place  in  less  time  than 
after  any  other  method  of  operating  that  I  have  ever  known. 

FISSURE    OR    IRRITABLE    ULCER    AT    THE    TERMUS'AL    EIS'D    OF 

THE    RECTUM 

To  comprehend  the  treatment  of  this  affection  with  the 
galvano-cautery  it  is  necessary  to  understand  its  true  pathol- 
ogy and  causation,  especially  the  latter.  Van  Buren  gives 
such  a  graphic  description  of  that  disease  that  I  prefer 
to  quote  in  toto :  "  There  is  no  disease  to  which  humanity 
is  liable — certainly  none  so  insignificant  in  extent — which 
is  capable  of  causing  more  intolerable  suffering  than  the 
ailment  generally  known  as  fissure  of  the  anus.  It  is  more 
properly  styled  irritable  ulcer  of  the  rectum,  for  this  desig- 
nation describes  accurately  the  true  pathological  nature  of 
the  disease.  The  ulcer  originates  in  a  fissure  or  crack  in 
the  delicate  integument  lining  the  orifice  of  the  anus,  or,  to 
speak  with  greater  exactness,  in  the  mucous  membrane  just 
about  assuming  the  character  of  skin  which  lines  that  por- 
tion of  the  rectum  embraced  by  the  sphincter-ani  muscle. 
Doubtless  there  are  cracks  and  fissures  occurring  frequently 
in  this  exposed  locality,  under  the  influence  of  costiveness 


126       electro-HtEmostasis  in  operative  surgery. 

and  violent  stretcMng,  whicli  get  well  promptly  without 
their  existence  having  been  suspected;  and  others  again 
which  last  a  longer  or  shorter  time,  and  give  but  little 
trouble.  But  in  certain  conditions  of  the  system,  and  where, 
under  the  necessity  imposed  by  habitual  constipation,  this 
forcible  distention  is  repeated  daily,  the  fissure  fails  to  heal 
promptly ;  and  then,  as  nnder  all  similar  circumstances  of 
constantly  repeated  mechanical  irritation,  inflammation  de- 
velops itself  in  the  little  wound,  and  just  in  proportion  as 
the  inflammation  advances  the  effort  at  repair  diminishes, 
until  finally  it  ceases  entirely.  The  solution  of  continuity, 
or  ulcer  as  it  is  now,  being  still  exposed  to  constantly  recur- 
ring mechanical  violence  and  to  the  contact  of  chemically 
irritating  substances,  is  kept  thus  in  an  actively  inflamed 
condition  and  soon  puts  on  all  the  features  of  an  irritable 
ulcer." 

Van  Buren's  description  is  complete,  perfect,  and  accept- 
able in  all  respects,  except  that  the  causation  given  is  not 
fully  in  harmony  with  the  clinical  facts  as  I  have  observed 
them.  The  actual  cause  of  the  persistence  of  certain  fissures 
is  that  they  extend  outward  from  the  mucous  membrane 
to  the  skin,  and  a  small  pocket  is  formed  beneath  the  skin 
in  the  terminal  end  of  the  fissure.  That  portion  of  the  skin 
overlying  the  lower  end  of  the  fissure  in  the  mucous  mem- 
brane becomes  indurated  and  stands  outward  so  that  the 
pocket  remains  open  and  filled  with  irritable  substances, 
which  prevent  the  parts  from  healing.  Fissures  wholly  in 
the  mucous  membrane  and  not  having  this  pocket  heal 
promptly. 

Fig.  75,  A,  shows  a  sketch  of  the  anus  with  the  fissure 
and  pocket. 

The  diagnosis  is  completed  by  a  physical  examination. 
The  books  direct  that  the  parts  should  be  separated  and  a 
slight  inversion  produced,  which  brings  the  ulcer  or  part  of 
it  into  view.  It  is  possible  to  do  this  when  the  sphincter- 
ani  muscle  is  relaxed,  but  it  is  generally  contracted,  and  the 
patients  resist  the  efforts  to  bring  the  lesion  into  view. 


TREATMENT   OF  RECTAL   HEMORRHOIDS. 


127 


Tlie  most  satisfactory  examination  is  with  tlie  glass  endo- 
scope. In  fact,  that  is  the  only  instrument  with  w^hich  anal 
fissures  can  be  clearly  seen.  The  glass  tube  distends  the 
parts  sufficiently  to  lay  the  fissure  open  and  bring  it  fully 
into  view,  and  its  use  causes  no  suffering  on  the  part  of  the 
patient  and  is  far  more  agreeable  to  the  surgeon  than  rectal 
specula  or  endoscopes  in  general  use. 


'Hj:. 


Fig.  75. — A,  fissura  in  ano,  showing  indurated  edge  and  pocket ;  B,  treatment  with 
fine  cautery  point.     The  pocket  is  being  laid  open. 

The  treatment  consists  in  applying  cocaine  to  the  ulcer 
by  means  of  a  pipette,  a  small  Sims  speculum  is  introduced, 
and  then  I  lay  open  the  pocket  at  the  most  dependent  part 
of  the  fissure  with  a  fine  cautery  point.  (See  Fig.  75,  £.) 
This  exposes  the  entire  ulcerated  surface,   which  is   then 


128  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

cauterized  tlironghout,  but  only  superficially.  The  cauteri- 
zation slioulcl  include  the  indurated  edges  of  the  ulcer,  but 
should  not  be  carried  deep  into  the  mucous  membrane  ;  only 
far  enough  to  destroy  the  diseased  tissue.  No  after-treat- 
ment is  required.  The  charred  tissue  protects  the  parts 
below  until  healing  has  been  completed. 

The  treatment  is  not  sufficiently  painful  to  require  gen- 
eral anaesthesia,  and  relief  from  suffering  is  almost  immediate. 
The  ultimate  results  are  quite  as  satisfactoiy  as  the  old 
treatment  by  stretching  the  sphincter  to  divide  the  fibers  of 
the  sphincter  beneath  the  fissure. 

The  following  case  recently  treated  is  typical  of  many 
that  I  have  relieved  in  the  same  way  :  This  patient  became 
constipated  after  the  birth  of  her  third  child,  and  about  two 
months  after  that  confinement  began  to  have  all  the  symp- 
toms of  fissure  of  the  anus.  Her  physician  gave  her  oint- 
ments and  suppositories  of  various  kinds  to  use,  and  treated 
successfully  her  constipation,  but  she  obtained  no  relief 
from  her  rectal  j)ain.  After  three  months  of  suffering  her 
health  became  impaired  and  a  surgeon  was  called  in  consul- 
tation who  made  a  diagnosis  of  fissure,  and  advised  oper- 
ative treatment.  This  proposition  was  accej)ted  by  the 
p)atient,  but  her  husband  was  fearful  of  anaesthetics,  so  he 
brought  her  to  my  office.  The  history  was  fully  given,  in- 
cluding the  fact  that  she  had  been  treated  with  local  appli- 
cations, but  finding  no  relief  had  given  up.  No  mention 
was  made  of  the  proposed  operation.  A  well-developed 
irritable  ulcer  was  found,  and  I  suggested  immediate  treat- 
ment, and  the  patient  agreeing,  I  operated  there  and  then. 
The  patient  told  me  that  I  caused  less  pain  than  the  exam- 
ination made  by  the  surgeon  who  had  previously  seen  her. 
When  I  asked  her  why  she  had  not  told  me  about  that,  she 
replied  that  she  wished  to  find  out  if  I  would  advise  the  same 
treatment  or  something  else  that  would  relieve  her  without 
having  to  take  an  anaesthetic.     Her  recovery  was  perfect. 


CHAPTER  XIV 

THE  TEEATMEISTT  OF  NEOPLASMS  OF  THE  SKIIST  AI^D  MUCOUS 
MEMBRAJSTES   WITH    THE    ELECTRO-CAUTEEY    Al^D    ELECTEOLYSIS 

My  attention  has  been  called  to  tliis  subject  especially 
by  seeing  three  patients  who  were  treated  a  long  time  ago, 
one  with  electrolysis  and  two  with  galvano-cautery.  The 
results  were  so  very  satisfactory  that  they  recalled  many 
other  cases  equally  complimentary  to  this  method  of  treat- 
ment. One  of  the  three  cases  was  a  nevus  situated  between 
the  eyebrows  of  a  child  five  months  old.  The  skin  cover- 
ing the  elevation  was  of  a  bluish  red  for  about  half  an  inch 
across,  and  three  quarters  of  an  inch  vertically.  The  tumor 
disappeared  on  pressure,  showing  that  the  enlarged  vessels 
were  mostly  in  the  cellular  tissue.  It  was  growing  very 
rapidly.  Electrolysis  was  employed,  and  that  child  is  now 
a  boy  fourteen  years  old,  with  no  trace  of  the  nevus  or  the 
treatment  to  be  seen.  The  second  case  was  one  of  epithe- 
lioma of  the  lower  lip  of  a  lady.  She  was  examined  by  a 
surgeon  of  reputation,  who  advised  its  removal.  I  fully 
<?onfirmed  the  diagnosis  by  clinical  and  microscopic  exami- 
nation, and  removed  the  growth  with  the  galvano-cautery. 
It  is  now  four  years  since  that  opei^ation,  and  there  is  no 
deformity  of  the  lip  nor  any  trace  of  the  disease.  The  third 
case  was  nevus  pilaris,  or  hairy  papilloma  on  the  cheek. 
This  was  removed  with  the  cautery,  and  there  is  only  a  small 
speck  of  scar  tissue,  which  is  barely  visible  on  close  inspec- 
tion. A  hundred  or  more  cases  to  illustrate  the  results  of 
this  mode  of  treatment  might  be  given,  but  these  will  suf- 
fice to  bring  the  subject  to  the  attention  of  the  reader. 

129 


130  ELECTRO-H^MOSTASIS  IN   OPERATIVE  SURGERY. 

Excepting  in  vascular  tumors,  in  wliicli  tlie  large  vessels 
are  subcuticular,  and  in  whicli  it  is  desirable  to  preserve 
tlie  skin  covering  the  vascular  growth,  the  galvano-cautery 
best  answers  the  purpose  in  all  cases.  In  the  exceptional 
cases  electrolysis  gives  the  best  results.  Skill  and  accuracy 
in  operating  are  very  essential.  The  needles  should  be 
round-pointed,  so  that  they  may  close  their  tracks  and  pre- 
vent bleeding.  They  should  be  insulated  to  within  a  dis- 
tance from  the  point  nearly  the  length  of  the  diameter  of 
the  tumor.  This  enables  the  operator  to  bring  the  acting 
part  of  the  needle  into  contact  with  the  tissue  to  be  de- 
stroyed, and  yet  preserve  the  normal  skin  at  the  point  of 
puncture.  The  electric  current  used  should  be  strong 
enough  to  produce  chemical  decomposition  at  the  negative 
and  desiccation  or  cooking,  but  not  charring,  at  the  positive 
needle.  These  changes  in  the  tissue  are  manifested  by  its 
becoming  hard,  especially  along  the  line  of  the  joositive 
needle,  which  becomes  immovable  by  sticking  to  the  tissue. 
When  these  changes  have  taken  place  the  current  should  be 
reversed  and  continued  until  the  positive  needle  becomes  loose. 

If  the  needles  are  withdrawn  without  reversing  the 
current,  troublesome  haemorrhage  follows  and  interrupts 
the  treatment.  If  there  is  no  disposition  to  bleeding  when 
the  needles  are  partially  withdrawn,  they  should  be  re- 
moved and  again  introduced  into  the  parts  of  the  tumor 
remaining  unaffected,  and  the  current  used  as  in  the  first 
instance.  In  medium-sized  tumors  the  treatment  can  be 
completed  by  two  introductions  of  the  needle,  but  if  any 
part  escapes,  as  shown  by  the  soft  condition  due  to  the 
circulation  continuing  in  some  of  the  vessels,  the  procedure 
should  be  repeated.  The  needle  punctures  on  the  surface 
should  be  closed  with  collodion  to  prevent  the  entrance  of 
anything  that  might  cause  suppuration.  Usually  repair 
goes  on  favorably  along  with  the  absorption  of  the  de- 
stroyed tissue.  If  suppuration  takes  place  the  pus  should 
be  washed  out  through  the  needle  punctures,  and  drainage 
kept  up  with  a  few  horsehairs  or  some  twisted  silk. 


NEOPLASMS  OF  THE  SKIN  AND  MUCOUS  MEMBRANES.     131 

The  galvano-cauteiy,  certainly,  so  far  as  results  are  con- 
cerned, is  infinitely  tlie  best  method  of  removing  neoplasms 
from  the  skin  and  mucous  membranes,  excepting  in  such 
cases  as  Just  mentioned.  When  properly  employed  it 
causes  less  pain  during  the  operation,  the  recovery  is  much 
more  prompt  and  complete,  and  the  scar  tissue  that  follows 
is  v«ry  much  less  in  extent  than  by  any  other  method  of 
dealing  with  these  growths.  The  objections  to  the  various 
forms  of  caustics,  such  as  nitric  and  chromic  acid,  are  that 
they  do  not  completely  destroy  the  tissue ;  that  they  cause 
very  much  more  pain  and  suffering ;  that  they  are  not  so 
certain  in  their  results ;  and  that  they  leave  far  more  un- 
sightly scars. 

That  which  comes  the  nearest  to  the  galvano-cautery  is 
the  paste  of  chloride  of  zinc,  lactic  acid,  and  caustic  potash. 
These  have  been  employed  by  Dr.  I.  N.  Bloom,  of  Louis- 
ville, Ky.  Of  any  results  with  which  I  am  familiar  his 
approach  most  nearly  those  obtained  by  the  galvano-cautery ; 
but  they  fall  short  of  accomplishing  the  objects  that  are 
obtained  so  thoroughly  and  completely  by  the  use  of  the 
galvano-cautery.  Considerable  practice  is  necessary  to  ac- 
quire facility  in  technique. 

The  great  object  is  to  thoroughly  destroy  the  diseased 
or  abnormal  tissue  with  the  cautery  at  a  degree  of  about 
red  heat,  and,  while  destroying  all  that  is  abnormal,  not 
to  go  beyond  the  boundary  line  or  encroach  upon  the 
normal  tissue.  It  is  very  important,  especially  in  vascular 
growths,  to  apply  the  cautery  to  the  tissue  to  be  destroyed 
before  turning  on  the  heat.  If  it  is  heated  and  then  ap- 
plied, there  is  very  great  danger  of  haemorrhage,  especially 
in  vascular  tumors.  A  small  cautery  j)oint  should  be  used, 
unless  the  growth  is  very  large,  and  it  is  most  convenient 
to  place  it  into  the  center  of  the  mass  to  be  destroyed  while 
it  is  cold.  The  heat  being  turned  on,  the  cautei^ization  or 
destruction  of  the  tissue  should  proceed  from  the  center 
toward  the  circumference,  so  as  to  make  it  complete  with- 
out going  beyond  the  boundary  of  abnormal  tissue.     It  is 


132  ELECTRO-H^MOSTASIS  IN   OPERATIVE  SURGERY. 

always  well  not  to  go  too  deep  at  first.  If  it  is  found 
that  there  is  still  some  diseased  tissue  deeper  dowm,  the 
ground  can  be  gone  over  again  until  the  destruction  is  com- 
plete. 

In  operating  upon  small  tumors  about  the  mouth,  cheeks, 
or  forehead  the  parts  should  be  held  perfectly  to  prevent 
twitching  of  the  muscles.  Neglect  of  this  may  cause  the 
cautery  to  slip  and  injure  the  normal  skin  and  lead  to  un- 
necessary scars. 

In  angioma,  nevus,  and  epithelioma,  especially  when  the 
mass  or  growth  is  large  and  vascular,  it  is  better  to  begin 
at  the  circumference  and  work  toward  the  center,  always 
using  the  cautery  at  a  dull-red  heat,  since  if  the  heat  is  too 
great — that  is,  white  heat — there  is  sure  to  be  bleeding. 
In  fact,  in  cases  of  angioma  it  is  impossible  sometimes  to 
operate  in  this  way  without  having  very  decided  hsemor- 
rhao"e.  In  such  cases  I  have  adopted  another  method  which 
answers  very  well,  and  that  is  to  seize  the  mass  with  a 
haemostatic  forceps  in  the  central  portion  or  where  the  ves- 
sels are  largest,  and  strongly  compress  it,  then  turn  on  the 
electric  heat,  and  desiccate  it  before  letting  go.  This  will 
control  the  bleeding  in  the  larger  vessels,  and  then  mth  the 
cautery  point  the  rest  of  the  tissue  at  the  outer  margins  of 
the  growth  can  be  destroyed  in  the  way  already  described. 
That  method  of  operating  can  also  be  done  in  cases  of  epi- 
thelioma, but  the  results  are  not  quite  so  satisfactory,  be- 
cause the  friable  tissue  breaks  down  in  the  grasj)  of  the 
haemostatic  forceps  and  so  can  not  be  controlled  in  that 
way  ;  but  in  small  vascular  growths  the  results  are  very  satis- 
factory in  operating  as  described. 

This  method  is  equally  applicable  in  case  the  part 
operated  upon  be  mucous  membrane  or  skin.  Where  the 
diseased  part  is  located  on  the  mucous  membrane,  say  of 
the  cervix  uteri,  the  lip,  the  tongue,  or  any  portion  of  the 
mouth,  the  pain  is  slight,  and  in  the  most  sensitive  cases  it 
is  only  necessary  to  use  a  little  cocaine  to  be  able  to  oper- 
ate without  causing  any  great  distress.     Indeed,  this  is  the 


NEOPLASMS    OF   THE  SKIN  AND   MUCOUS  MEMBRANES.     133 

most  painless  method  of  operating,  as  it  causes  mucli  less 
pain  than  any  caustic  or  paste  that  I  know  anything  about. 
In  fact,  it  is  not  necessary  to  employ  an  ansesthetic  except 
in  large  epitheliomatous  growths  about  the  face.  The  most 
sensitive  patients  usually  tolerate  well  the  operation  any- 
where on  the  skin,  unless  the  growth  is  unusually  large.  In 
case  one  fails  to  remove  all  the  diseased  tissue,  which  some- 
times happens,  it  is  very  easy  to  make  a  second  application 
after  the  healing  process  has  been  completed  and  the  eschar 
has  separated  and  come  away,  which  usually  happens  at  the 
end  of  a  week. 

The  condition  of  the  parts  when  the  operation  has  been 
well  done  is  simply  this :  All  the  tissues  are  burned  away 
or  destroyed,  and  the  surface  is  covered  with  a  thin  layer  of 
charred  tissue,  which  shows  as  a  black  mark  outlining  the 
extent  of  the  original  tumor.  A  few  hours  after  the  treat- 
ment the  mucous  membrane  or  skin  around  the  cauterized 
portion  becomes  quite  red,  but  this  redness  passes  off  by  the 
following  morning,  or  sometimes  very  much  sooner;  and 
then  all  that  remains  to  indicate  the  field  of  operation  is  the 
spot  of  charred  tissue,  which  is  not  by  any  means  unsightly. 
There  is,  of  course,  no  dressing  necessary.  The  char  forms  a 
perfect  crust,  under  which  the  tissues  heal  kindly  and  very 
quickly.  It  is  needless  to  say  that  the  operation  is  aseptic, 
and  hence  there  is  no  way  by  which  any  pathogenic  germs 
can  be  left  in  the  wound  to  set  up  inflammation.  This 
probably  accounts  for  the  rapid  healing,  as  in  about  five  or 
six  days  the  charred  tissue  usually  separates,  comes  away, 
and  leaves  a  red  surface  which  requires  no  further  care. 
When  the  charred  tissue  separates  the  surface  is  usually 
completely  healed,  and  differs  from  the  surrounding  tissue 
only  in  being  of  a  deeper  color.  During  the  healing  pro- 
cess the  parts  contract,  so  that  on  the  separation  of  the 
charred  crust  the  scar  is  very  much  smaller  than  it  was  at 
the  close  of  the  operation.  The  redness  fades  away  gradu- 
ally, and  at  the  same  time  the  parts  keep  contracting,  so  that 
in  the  course  of  time  the  scar  is  almost,  if  not  completely^ 


134  ELECTRO-H^MOSTASIS  IN  OPERATIVE   SURGERY. 

imperceptible.  A  scar  of  a  magnitude  that  is  noticeable  is 
left  only  in  case  the  tumor  is  very  large. 

A  point  of  interest  in  the  management  of  nevi  pilares, 
that  are  so  frequently  seen  on  the  face,  is  that  in  such  cases 
it  is  necessary  to  carry  the  cauterization  deep  down,  almost 
through  the  true  skin,  so  as  to  destroy  the  hair  bulb 
completely.  If  one  cauterizes  only  superficially,  the  hairs 
will  grow  up  again  and  no  great  benefit  will  result.  The 
cauterization  should  be  carried  down  deeply  into  the  center 
where  the  hairs  are,  and  then  continued  upward  and  out- 
ward toward  the  surface,  so  that  when  the  entire  growth  is 
destroyed  the  cavity  left  is  cone-shaped,  the  apex  of  the 
cone  being  deep  down  in  the  skin.  Cases  treated  in  this 
way  do  remarkably  well,  because  this  cone-shaped  opening 
contracts  nicely  and  the  results  are  finally  very  gratifying. 
I  have  in  mind  at  this  moment  a  large  number  of  such 
growths  on  the  face  which  were  so  treated.  The  great 
point  is  to  obtain  complete,  perfect  results  with  the  most 
desirable  cosmetic  effect,  and  the  least  possible  or  no  dis- 
figurement from  scars. 

This  method  of  operating  gives  vastly  better  results 
than  any  other  means  at  our  command.  From  quite  an  ex- 
tensive experience  I  know  that  the  results  obtained  are 
better  than  those  with  excision  by  means  of  a  knife.  In 
operating  with  a  knife  it  is  necessary  to  make  a  long  in- 
cision and  unite  the  parts  with  sutures,  and  the  result 
invariably  is  that  the  suture  marks  and  a  long  scar  are  left. 
This  is  the  fact  even  if  every  precaution  is  taken,  and  the 
best  possible  results  are  obtained  in  the  way  of  immediate 
union. 

In  case  there  is  any  suppuration,  as  may  happen  at  any 
time  in  spite  of  the  utmost  care  to  obtain  aseptic  conditions, 
there  will  sometimes  be  a  little  failure  of  union,  and  an 
ugly  scar  is  left  to  annoy  the  patient.  When  the  cautery 
is  used  no  dressing  is  necessary,  as  the  cauterized  or  charred 
tissue  is  itself  by  far  the  best  dressing  possible. 

Again,  if  we  compare  the  results  with  the  caustics,  such 


NEOPLASMS   OF   THE  SKIN  AND   MUCOUS  MEMBRANES.      I35 

as  uitric  or  chromic  acid,  the  advantages  are  markedly 
apparent  in  that  these  invariably  leave  a  very  ugly  scar  that 
does  not  disappear  completely,  and  remains  a  glaring  de- 
fect for  a  long  time  to  mar  the  beauty  of  the  patient.  The 
same  may  be  said  with  reference  to  the  use  of  pastes,  such 
as  already  have  been  alluded  to.  They  all  leave  very  ugly 
scars  compared  with  the  scar  that  is  left,  or  the  absence  of 
scar,  as  it  might  be  called,  when  the  cautery  is  employed. 
This  is  one  of  the  most  important  advantages  of  this  way  of 
operating ;  and  it  is  not  the  only  one,  for  the  method  has 
advantages  in  every  particular  over  all  other  known  methods. 
My  attention  was  first  called  to  the  galvano-cantery  in  the 
treatment  of  cancer  of  the  uterus  by  my  friend  Dr.  John 
Byrne,  and  I  have  always  felt  grateful  to  him  for  his  valua- 
ble instruction.  Dr.  George  M.  Beard  taught  me  how  to 
pi'actice  electrolysis  in  the  treatment  of  vascular  nevi,  and 
I  desii'e  to  pay  tribute  to  the  memory  of  that  gifted  man 
who  was  one  of  the  first  to  develop  scientific  electro-thera- 
peutics. 


10 


CHAPTEE   XV 

ASEPSIS    AND    ANTISEPSIS    IN    SUEGEEY 

Success  in  surgery  depends  upon  cleanliness  as  well  as 
skillful  and  accurate  operating,  and  in  estimating  one's  work 
tlie  methods  of  obtaining  aseptic  conditions  by  means  of 
antiseptic  methods  must  be  taken  into  account. 

Therefore  I  have  deemed  it  expedient  to  give  a  chapter 
on  this  subject  to  show  the  conditions  under  which  my 
operative  work  has  been  done.  Much  of  detail  has  been 
omitted  to  make  room  for  that  which  is  considered  impor- 
tant in  the  writer's  practice. 

Surgeons  are  faiiiy  well  united  in  their  opinions  regard- 
ino-  the  beneficence  of  the  modern  discoveries  in  bacteri- 
ology,  the  germ  causation  of  disease,  and  the  inestimable 
value  of  disinfection  and  sterilization  as  means  of  preven- 
tion of  surgical  affections.  Harmony  prevails  also  to  a 
gratifying  extent  regarding  the  principles  of  aseptic  and 
antiseptic  surgery.  Still  there  is  much  diversity  of  opinion 
regarding  the  methods  of  practical  cleanliness  in  all  opera- 
tive work. 

There  are,  indeed,  many  ways  of  trying  to  keep  wounds 
free  from  septic  contamination  and  keeping  them  clean 
during  the  healing  process.  In  fact,  there  are  nearly  as 
many  methods  as  there  are  distinguished  surgeons.  The 
aim  and  objects  are  the  same  mth  all,  but  the  means  by 
which  the  results  are  obtained  differ  in  detail  very  greatly. 
The  methods  of  asepsis  in  surgery  were  very  complicated 
at  first,  and  they  are  still  somewhat  so.  The  tendency  has 
been  toward  simplicity,  and  in  proportion  to  the  discovery 
of  uncomplicated  methods  efficiency  has  been  attained. 

136 


ASEPSIS  AND  ANTISEPSIS  IN  SUKGERY.  13  7 

The  same  light  that  revealed  the  part  that  germs  play 
in  the  causation  of  disease,  and  that  made  clear  the  preven- 
tion of  all  kinds  of  sepsis,  led  with  equal  scientific  certainty 
to  improvements  in  sanitary  architecture  or  construction  of 
hospitals  and  homes  for  the  sick. 

In  this  department  of  hygiene  and  preventative  medi- 
cine the  progress  toward  perfection  has  been  so  vast  and 
varied  that  volumes  might  be  filled  with  the  records. 
Specialists  in  sanitaiy  science,  aided  by  skilled  engineers, 
intelligent,  honest  plumbers — there  are  such  nowadays — 
make  the  selection  of  proper  sites  for  institutions  for  sick 
and  injured,  and  by  faultless  construction  fulfill  all  the  re- 
quirements in  foundations,  ventilation,  lighting,  heating,  and 
draining.  The  recent  improvements  in  this  regard  are  well- 
nigh  perfect  and  quite  familiar  to  all  who  take  an  interest 
in  the  subject.  The  sj)ecial  efforts  now  being  made  relating 
to  sanitary  architecture  are  directed  to  facilitating  disinfec- 
tion and  maintenance  of  cleanliness.  This  is  more  directly 
related  to  operative  surgery ;  hence  I  may  with  propriety 
note  some  of  the  improvements  that  have  been  recently 
made  and  especially  connected  with  the  subject  now  under 
consideration.  The  first  architectural  principles  in  the 
construction  of  rooms  for  the  sick  are  to  guard  against 
places  for  the  accumulation  of  dirt  and  lodgment  of  dis- 
ease germs. 

The  best  work  on  design  and  construction  of  institu- 
tions for  the  care  of  the  sick  that  I  have  seen  anywhere  is 
that  of  Marshall  L.  Emery,  an  architect  who  has  taken 
great  interest  in  this  branch  of  his  art.  Evidently  he  first 
informed  himself  by  consultation  with  medical  men  regard- 
ing the  requirements  of  a  hospital  and  endeavored  to  meet 
them.  The  following  is  taken  from  Mr.  Emery's  writing 
on  the  subject : 

SANITABT   HOSPITAL    CONSTRUCTIOlSr 

A  modern  hospital,  designed  and  arranged  to  meet  mod- 
ern requirements,  is  the  result   of  an  evolution  extending 


138  ELECTRO-H^MOSTASIS  IN  OPERATIVE   SURGERY. 

over  many  years  and  embracing  the  conscientious  labors  of 
many  able  investigators  in  both  the  medical  and  architec- 
tural professions. 

The  progress  in  the  science  of  medicine  and  surgery  has 
made  from  time  to  time  new  demands  upon  the  architect 
and  the  builder,  and  while  a  great  many  of  these  demands 
have  been  fully  met,  there  are  some  which  require  still  fur- 
ther study  and  invention  in  both  the  material  and  the  mode 
of  construction.  It  may  be  assumed  for  present  pui'poses 
that  the  science  of  hospital  planning  is  well  advanced 
toward  the  ideal ;  the  size,  shape,  and  sequence  of  the 
various  dej)artments  have  been  gradually  reduced  to  a 
typical  or  standard  arrangement  which  is  capable  of  being 
carried  out,  and  a  satisfactory  result  obtained  where  space 
and  means  are  available.  In  the  matter  of  constructive 
detail,  however,  the  requirements  of  modern  medical  science 
are  greater  than  can  be  pi'ovided  by  the  means  and  methods 
of  building  at  present  in  use.  This  may  be  show^n  by  taking 
for  example  a  single  room,  and  as  an  operating  room  is 
probably  the  most  severe  in  its  demands,  it  may  be  taken 
as  a  type  for  all  the  rest,  on  the  assumption  that  any  detail 
which  meets  the  conditions  in  such  a  room  will  be  satisfac- 
tory in  any  of  the  others,  though  the  matter  of  cost  would 
undoubtedly  preclude  the  use  of  this  construction  through- 
out the  whole  building. 

An  operating  room  consists,  in  common  with  all  other 
rooms,  of  the  following  parts :  Walls,  floor,  ceiling,  doors, 
windows,  sash,  door-  and  window-jambs  and  casings  and 
base.  All  the  matters  of  detail  must  conform  to  the  follow- 
ing principles :  They  must  be  hard,  non-porous,  durable,  as 
free  from  joints  of  any  kind  as  possible,  and  fi'ee  from  all 
sharp  corners  or  angles,  or  any  other  feature  tending  to  col- 
lect dirt  or  septic  matter,  or  offer  any  obstruction  to  its 
ready  and  complete  removal ;  furthermore,  they  must  be  of 
such  a  nature  that  they  shall  not  change  their  size,  shape, 
or  positions  after  erection,  but  shall  remain  as  originally  set 
up — in  short,  they  must  not  shrink,  warp,  or  settle,  or  do 


ASEPSIS  AND   ANTISEPSIS  IN  SURGERY.  139 

any  of  the  disagreeable  things  that  building  material  is 
constantly  doing. 

In  some  of  the  details  the  principles  are  easily  lived  up 
to,  and  with  some  forms  of  construction  and  sufficient 
means  many  of  the  demands  can  be  complied  with ;  but 
even  at  best,  there  are  some  required  features  which  present 
material  and  building  methods  can  not  provide. 

It  might,  of  course,  be  possible,  theoretically,  to  design 
a  room  where  all  the  conditions  should  be  supplied,  but 
such  a  room  would  be  a  practical  impossibility,  owing  prin- 
cipally to  its  great  cost  and  the  difficulty  of  procuiing 
sufficiently  skilled  labor  in  its  construction. 

The  greatest  obstacle  to  be  overcome  lies  in  the  almost 
imperative  necessity  for  the  use  of  wood  to  a  greater  or  less 
extent,  depending  upon  the  money  to  be  expended. 

We  can  best  proceed  by  taking  up  the  details  of  con- 
truction  as  already  enumerated,  beginning  with  the  walls. 
One  or  more  of  these  will,  of  course,  be  an  exterior  wall  con- 
taining one  or  more  windows.  As  the  ordinary  form  of  con- 
struction suffices  and  is  generally  familiar,  we  shall  discuss 
but  one  feature,  namely,  that  of  insulation.  All  outside  w^alls 
have  to  be  built  to  prevent  condensation  of  the  warm  air  of 
the  room,  and  to  prevent  loss  of  heat  by  conduction  through 
the  material  of  the  wall.  This  is  generally  accomplished  in 
one  of  three  ways — building  the  wall  so  as  to  leave  a  hollow 
space  in  the  wall  itself  of  from  two  to  four  inches ;  building 
in  the  wall  a  course  of  hollow  bricks  extending  from  bot- 
tom to  top ;  or  lining  the  wall  on  the  inside  with  hollow 
terra-cotta  tile.  In  cheap  construction  wood  furring  strips 
are  used  to  which  the  lathing  is  nailed,  an  air  space  being 
formed  thereby  about  equal  to  the  thickness  of  the  furring 
strips,  usually  from  one  to  two  inches.  Either  of  the  first 
three  methods  is  good,  and  possibly  the  first  the  best,  if 
properly  built ;  though  the  terra-cotta  tiles  are  most  fre- 
quently used. 

The  partition  or  interior  walls  may  be  of  three  forms : 
Solid  brick,  rough,  pressed,  or  enameled ;  hollow  brick,  terra- 


140  ELECTRO-H^MOSTASIS  IN   OPERATIVE   SURGERY. 

cotta  tiles,  or  solid  plaster  cement ;  or  a  light  framework, 
for  high  ceilings,  long  spans,  etc.  The  solid  brickwork  is  the 
best ;  but  for  small  walls,  or  where  walls  are  carried  by  the 
floor  construction  or  girders,  it  is  generally  more  advan- 
tao-eous  to  use  one  of  the  latter  forms.  The  hollow  tile 
ran2:e  from  two  inches  to  eight  inches  in  thickness,  and 
averao-e  about  sixteen  inch  squares.  They  are  laid  in  mortar 
in  very  much  the  same  manner  as  common  brick.  The  solid 
plaster  partitions  have  come  into  use  within  this  last  five 
years,  and  have  many  advantages.  They  cost  less  than  solid 
brick  or  terra-cotta,  and  as  they  are  but  two  to  tw^o  and  a  half 
inches  thick  they  save  considerable  floor  space.  They  are 
lighter  than  brick  partitions  and  do  not  require  any  spe- 
cially heavy  floor  construction,  but  can  be  placed  where  de- 
sirable without  reference  to  beams  and  girders. 

The  floor  construction  is  important,  as  the  ceilings  and 
other  matters  depend  largely  on  their  stability. 

If  the  money  at  disposal  will  allow,  steel  beams  should 
of  course  be  used ;  and  if  not,  then  Georgia  pine  beams  of 
large  section  and  as  free  from  sap  as  j)ossible. 

In  the  case  of  steel  beams,  the  spaces  between  beams 
may  be  spanned  in  various  ways — either  by  several  forms  of 
hollow-tile  arches,  or  by  a  number  of  patented  systems 
consistino;  of  a  combination  of  iron  bars  or  nettins^  and  con- 
Crete.  There  is  little  choice  among  the  several  forms  for 
hospital  use.  Where  the  loads  on  the  floors  are  compara- 
tively light,  the  cost  is  generally  in  favor  of  concrete  and  iron. 
If  wood  beams  are  used,  there  should  always  be  double 
floors  laid,  with  layers  of  water-  and  fire-proof  material  be- 
tween them,  unless  a  tile  or  other  non-combustible  flooring 
be  used.  Tile,  concrete,  or  mosaic  floors  are  sometimes  laid 
on  wood  beams,  but  the  result  is  bound  to  be  unsatisfactory, 
and  the  practice  is  to  be  avoided  as  far  as  possible.  Should 
it  be  necessary,  however,  it  is  accomplished  by  nailing  cleats 
to  the  sides  of  the  beams  two  to  three  inches  below  their 
tops,  to  which  a  rough  floor  is  nailed.  On  this  rough  floor 
is  laid  a  bed  of  concrete  to  within  about  an  inch  of  the 


ASEPSIS  AND   ANTISEPSIS  IN  SURGERY.  141 

finished  floor ;  this  inch  being  left  for  the  tile,  marble,  or 
cement  finishing  surface.  As  ceilings  are  almost  invariably 
finished  in  plaster,  it  is  only  necessary  in  the  ceiling  con- 
struction to  provide  a  sufiiciently  strong  and  rigid  foundation 
to  support  the  plaster.  If  steel  beams  be  used,  a  system  of 
light  iron  framework  is  secured  to  the  lower  edges  or 
"  flanges  "  of  the  beams,  upon  which  wire  or  sheet-metal  lath 
is  stretched  and  plastered. 

In  the  use  of  wood  beams  the  wire  or  metal  lath  is 
nailed  directly  to  the  beams,  or  to  wood  furring  strips  nailed 
to  them. 

The  floors  may  be  finished  in  either  tile,  marble,  mosaic, 
concrete,  or  wood  block.  The  first  three  forms  are  all  familiar, 
and  of  these  the  tile  is  preferable,  provided  a  hard  "  vitrified  " 
tile  be  used  not  exceeding  two  inches  square,  larger  tiles 
being  apt  to  loosen.  Hardwood  blocks,  about  two  inches 
wide  and  twelve  inches  long,  put  down  on  a  concrete  foun- 
dation with  asphaltic  cement,  have  been  used  lately  to  some 
extent,  but  as  they  cost  nearly  as  much  as  tile  or  mosaic, 
and  have  to  be  kept  constantly  "  filled,"  waxed,  or  varnished 
there  seems  to  be  little  if  any  advantage  in  their  use. 

If  necessary  to  use  an  ordinary  wood  floor,  it  should  be 
laid  double,  as  already  mentioned ;  the  upper  flooring  not 
exceeding  two  inches  in  width,  and  of  hard,  close-grained 
wood,  thoroughly  seasoned,  dry,  and  well  nailed.  The  rough 
or  under  floor  should  be  laid  diagonally  across  the  floor 
beams  and  the  top  or  finished  floor  laid  at  right  angles  to 
them.  The  top  floor  should  be  smoothed  off  and  planed 
over  the  whole  surface,  and  "  filled  "  and  finished  imme- 
diately after. 

Wood  floors  are  often  laid  on  a  fireproof  construction 
by  bedding  wood  sleepers  two  inches  thick  on  the  steel 
beams  and  anchoring  them  there  by  leveling  up  to  the  top 
of  the  sleepers  with  concrete,  and  then  laying  a  double  floor^ 
as  just  described. 

The  obvious  objections  to  wood  as  a  flooring  material 
will,  of  course,  apply  to  all  wood  floors,  and  they  should 


142  ELEOTRO-H^MOSTASIS  IN   OPERATIVE  SURGERY. 

never  be  used  except  where  necessitated  by  lack  of  means. 
A  cement  floor  will  cost  but  little  more  than  a  good  wood 
floor,  and  is  certainly  far  better  in  sanitation,  permanence 
and  ultimate  economy. 

The  best  material  for  wall  and  ceiling  finish  is  "  Keen's  " 
cement,  the  best  brands  being  imported  from  England, 
where  it  is  more  largely  used  in  hospital  construction  than 
here.  When  properly  applied  it  presents  a  very  dense, 
hard  surface,  and,  skillfully  worked,  is  capable  of  great 
smoothness  and  polish.  Incidentally  it  may  be  mentioned 
that  it  is  the  basis  of  artificial  marbles.  The  cost  of  this  ma- 
terial is  a  great  drawback,  and  in  ordinary  work  its  use  is 
limited  to  wainscots,  bases,  window  sills,  and  similar  exposed 
places.  For  the  upper  part  of  the  w^alls  and  for  ceilings 
patent  plaster  or  "  dry  mortar "  answers  very  well,  though, 
while  not  so  dense  or  hard  as  the  "  Keen's  "  cement,  it  is  a 
great  improvement  over  common  lime  mortar.  "Patent 
plaster "  is  merely  a  basis  of  plaster  of  Paris  mixed  with 
sand  and  a  retarding  agent,  kept  secret  by  the  makers, 
which  slows  the  setting  of  the  plaster  of  Paris  sufficiently 
to  allow  the  w-alls  to  be  properly  worked.  The  mixing  and 
proportioning  of  patent  plasters  is  done  by  machinery,  and 
is  consequently  done  in  a  more  thorough  manner  than  if 
done  by  the  hand  of  an  indifferent  laborer,  w^hich  is  one 
reason  for  its  superiority  over  common  plastering  mortar. 

The  angles  formed  by  the  walls,  and  the  walls  and  ceil- 
ings, should  be  "  rounded  "  or  finished  with  a  cove,  instead 
of  forming  a  sharp  corner.  This  cove  should  not  be  too 
large,  as  it  will  be  liable  to  crack  if  formed  wdth  a  large 
radius.  A  radius  of  two  inches  w^ill  be  found  sufficient  for 
all  purposes,  and  is  easily  made. 

The  forming  of  the  curve  in  wall  and  ceiling  angles, 
while  simple,  requires  a  considerable  degree  of  care  and 
skill  on  the  part  of  the  plasterer  to  make  it  straight  and 
true,  and  to  make  all  miters  and  intersections  meet  and 
join  properly. 

The  angle  between  the  floor  and  wall  should  be  coved 


ASEPSIS  AND  ANTISEPSIS  IN  SURGERY.  143 

in  the  same  manner,  and  where  a  tile,  mosaic,  or  cement 
floor  is  used  there  is  no  trouble ;  where  a  wood  floor  is 
used,  however,  it  is  impossible  to  make  a  joint  or  connec- 
tion between  the  Avood  and  plaster  which  will  not  open, 
even  if  it  be  made  tight  when  first  put  down.  This  is  an- 
other strong  objection  to  the  wood  floor. 

If  tile  be  used  for  a  wainscot  or  wall  finish  the  coved 
corners  are  formed  in  the  tile  themselves,  and,  if  necessary, 
special  tile  may  be  designed  to  suit  diiferent  conditions  or 
positions. 

The  demands  of  hospital  design  present  little  that  can 
not  be  provided  in  construction  as  far  as  walls,  floors,  and 
ceilings  are  concerned.  With  doors  and  windows  the  case 
is  diiferent,  and  it  is  here  especially  that  future  study  and 
invention  are  to  be  employed. 

The  difiiculties  presented  may  be  best  appreciated  by 
referring  to  drawings.  Fig.  76  shows  a  window  frame  and 
sash  in  ordinary  work,  and  in  fact  even  in  some  hospital 
work.  A  glance  will  show  how  unfit  it  is  for  any  use 
where  it  is  essential  to  obtain  thorough  cleanliness;  tlie 
corners  and  angles  offer  abundant  opportunity  for  the  col- 
lection of  dust,  which  ^^dll  increase  as  the  wood  shrinks 
and  joints  open. 

Fig.  77  shows  a  window  designed  to  oifer  as  far  as  pos- 
sible the  least  chance  for  tke  lodgment  of  dirt  and  least  ob- 
struction to  its  removal,  but  even  this  construction  leaves 
much  to  be  desired.  The  angle,  A,  between  the  casing  and 
jamb  has  to  be  covered  with  a  molding,  because  it  is  im- 
possible to  make  the  wood  and  plaster  join  together  closely 
enough  to  avoid  a  ragged  joint,  and  even  wath  this  mold- 
ing there  will  be  an  open  joint  somewhere  unless  the  work- 
manship is  far  above  the  average ;  and  the  sash  itself  ofl^ers 
a  sharp  angle  between  the  glass  and  wood,  which  it  is  as 
yet  impossible  to  avoid. 

The  stop  bead  against  the  stile  offers  another  joint,  £, 
which  is  sure  to  open  through  the  effect  of  atmospheric 
changes ;  still,  the  improvement  of  one  over  the  other  is 


lU 


ELECTRO-HiEMOSTASIS   IX  OPERATIVE  SURGERY. 


quite  encouraging,  and   the  time   ^vill   undoubtedly   come 
Avhen  many  present  objections  will  be  overcome. 


SECTION 
THROUGH  JAMB 


BRICK  OR  STONE  WALL 


WOOD  INNER  4  ^5^ 

51LL  ^^^^^ 


FURRING 


WOOD  TRIM- 


PLASTER 


:/ 


5KETCH 

OF 
U5UAL  rORM 

OF 

WINDOW  FRAME 

IN 
,MA50MRY  WALLS 


J  ELEVATION  OF 
JiNSIDE  LOWER  CORNER 


Fig.  76. 


What  is  true  of  the  windows  is  equally  true  of  the 
doors.     Fig.  78  shows  a  door  in  an  ordinaiy  twelve-inch 


ASEPSIS   AND   ANTISEPSIS  IX  SURGEHY. 


145 


partition  finished  in  the  usual  way,  and  Fig.  79  shows  the 
best  that  can  be  done  at  present  in  the  way  of  elimination 
of  the  corners,  joints,  etc.,  which  remain  and  are  objection- 

5ECTION 

THROUGH  JAMB 


WOOD  TRIM 

CEMENT  INNER  SILL    Wi 


PLANTER  JAMB- 


BRICK  OR  5T0NE\ 
WALL 


^^^JTER RA  COTTaJ F^URRir  ,0 


ami 


PLA5TER^ 


:^ 


5HETCH  OF 

IMPROVED  FORM 

OFWINDOW  FRAME 

m  MASONRY  WALL5 
FOR  HOSPITAL  USE 


ELEVATION  OF  INSIDE  LOWER  CORNER 


Fig 


able,  but  at  present  unavoidable.  Where  the  partition  of 
wall  is  less  than  five  or  six  inches  thick  it  is  necessary  to 
have  a  casing  on  one  side,  and  in  a  two-  or  three-inch  ^vall  a 
casing  on  both  sides  is  necessary.    (See  Fig.  80.) 


146  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

AVliere  a  casiug  is  used,  the  cove  at  the  floor  is  inter- 
rupted, and  more  corners  formed.  The  wood  casing  is 
usually  received  by  a  marble  base  block,  which  prevents 


ELEVATION 

OF 

UPPER  CORNER 


rPLASTER 


PANELLED  WOODJAMB 


SKETCH  OF  USUAL  FORM 
OF  DOOR  FRAME 
AND  FINISH 

IN  THICK  WALL5 


It  J."  •J>"\^'-''>1 


PLA5TER 


WOOD  TRIM ^ 
SECTION  THROUGH  JAMB 


Fig.  78. 


ASEPSIS  AND   ANTISEPSIS  IN  SURGERY. 


147 


the  casing  reaching  to  the  floor,  where  it  is  liable  to  injury 
by  frequent  wetting  in  washing. 


SKETCH  OF 
IMPROVED  FORM 
OF  DOOR  FRAME 
AnDFmi5H  f 

FOR  H05P1TAL5  / 


PLASTER- 
ROUNDED  CORNER 

5ECTION  THROUGH 
JAMB 

Fig.  79. 


Where  the  casino^  is  omitted,  the  cove  at  the  floor  re- 
turns  around  the  wall  jamb,  or  finishes  against  the  wood 
door  jamb. 

With  reference  to  the  doors  themselves,  the  usual  pan- 


148 


ELECTRO-H^MOSTASIS  IN   OPERATIVE   SURGERY. 


eled  door  is  obviously  objectionable,   on   account   of  tlie 
numerous  shar^D  corners  and  angles. 

The  best  substitute  for  practical  use  is   a  "solid  ve- 


ELEVATiON 

OF 

UPPER  CORISEFI 


VENEERED  DOOR 


PLAIN  JAMB • 
WOODTRIM 


2"  WALL 

^PLASTER 


5ECTI0N  THROUGH  JAMB 

5KETCH  5H0W1NG  IMPROVED  FORM 
OF  DOOR  FRAME  AMD  FIHISH,  WHEN 
HECE55ARY  TO  U5E  WOOD  TRIM. 


SECTION  THROUGH  JAMB 

Fig.  80. 


ASEPSIS  AND  ANTISEPSIS  IN  SURGERY.  I49 

neered  "  door ;  that  is,  a  door  formed  of  a  glued-up  pine 
core,  and  veneered  on  sides  and  edges  with  a  hardwood 
veneer,  forming  a  perfectly  plain  surface,  which  may  be 
kept  filled  and  polished. 

Marble  doors  have  been  used  to  a  very  limited  extent, 
but  they  are  heavy  and  expensive,  hard  to  move,  and  unless 
the  hinges  or  pivots  are  very  hard,  and  carefully  made  and 
adjusted,  they  are  liable  to  wear  down  and  sag.  The  mar- 
ble, however,  is  porous,  easily  stained,  and  altogether  the 
most  objectionable  of  all.  Bronze  doors  would  answer  best, 
but  they  are  too  expensive  for  hospitals  as  a  general  rule. 

HOSPITAL    PLUMBING 

In  the  matter  of  plumbing,  improvements  in  material 
and  fixtures  have  reduced  in  a  great  degree  many  of  the 
difficulties  formerly  encountered  in  the  proper  equipment 
of  hospitals.  Fixtures  for  almost  all  purposes  are  now 
made  of  heavy  glazed  earthenware,  in  designs  or  forms 
needing  no  encasing  or  surrounding  material.  A  porcelain 
bath  tub  is  a  typical  example ;  when  set  it  is  complete,  no 
wood  curbing  or  boxing  being  required,  as  in  the  case  of 
the  older  copper-lined  tub. 

The  price  of  these  earthenware  goods  is  practically 
within  the  reach  of  an  institution  with  but  limited  means ; 
for  instance,  they  are  now  being  used  in  a  certain  small  vil- 
lage hospital,  costing  less  than  eight  thousand  dollars. 

In  some  ways,  however,  the  "  improvements  "  in  modern 
plumbing  fixtures  are  of  doubtful  character,  such  as  a  wash 
basin  with  supply  and  waste  cocks  operated  by  treadles  on 
the  floor.  In  a  general  way  the  questionable  value  of  these 
improvements  lies  in  their  complexity,  rendering  them  diffi- 
cult to  keep  clean  or  to  keep  in  order.  The  number  of 
valve  mechanisms,  traps,  wastes,  etc.,  is  almost  without  end, 
while  the  really  desirable  patterns  are  very  few. 

In  short,  the  simplest  form  of  any  fixture  w^th  its  acces- 
sories is  always  the  best,  provided  the  construction  is  satis- 
factory.    A  plain  "  S  "  trap  with  vent  connection  seems  at 


150  ELECTRO-HiEMOSTASIS  IN  OPERATIVE  SURGERY. 

tlie  present  stage  of  progress  to  be  the  best  to  be  had,  and 
a  "  standing  "  waste  and  ov^erflow  the  most  satisfactory  for 
general  use.  By  a  "  standing  "  waste  and  overflow  is  meant 
a  simple  tube  whose  lower  end  fills  the  outlet  of  bowl,  sink, 
or  tub,  and  whose  upper  end  is  open,  the  tube  standing 
vertically,  and  its  height  determining  the  depth  of  w^ater  in 
the  fixture.  Such  a  waste  is  the  simplest  possible  thing  to 
keep  clean,  and,  being  wholly  exposed,  is  always  open  for 
complete  inspection. 

The  trap  should  in  all  cases  be  placed  as  near  the  outlet 
of  the  fixture  as  it  is  possible  to  get  it,  and  the  w^aste  from 
fixture  to  trap  should  be  perfectly  straight.  The  strainer 
in  the  outlet  of  the  fixture  should  be  removable  so  that  the 
waste  can  be  thoroughly  cleaned. 

The  bad  air  in  many  bath  and  toilet  rooms  is  due  to  the 
fouling  of  the  inaccessible  waste  and  overflow  connections 
from  fixture  outlets  to  traps,  and  these  same  connections 
may  easily  form  favorable  germinating  places  for  dangerous 
bacilli. 

The  whole  aim  in  the  plumbing  of  a  hospital,  as  well  as 
any  building,  should  be  the  greatest  possible  simplicity. 
The  number  of  fixtures  should  be  cut  down  to  the  lowest 
possible  minimum,  they  should  be  grouped  together  as 
nearly  as  possible  to  a  few  vertical  lines,  and  the  fixtures 
themselves  should  be  of  the  best  material  and  plainest 
design  and  construction  consistent  with  specific  require- 
ments. 

The  arrangement  of  fixtures  in  the  various  rooms 
should  be  such  as  to  permit  all  piping  to  and  from  them  to 
be  run  in  the  most  direct  manner  and  so  as  to  make  the 
distance  from  main  lines  of  supply  and  waste  as  short  and 
as  straight  as  possible.  All  waste  pipes  should  have  a 
pitch  of  not  less  than  one  quarter  of  an  inch  to  a  foot.  All 
bends  should  be  of  large  radius  and  clean-outs  placed  at 
frequent  and  readily  accessible  points.  All  connections,  at 
least  in  the  rooms  containing  the  fixtures,  should  be  made 
with  screw  joints,  so  as  to  be  easily  taken  down  and  put  up. 


ASEPSIS   AND  ANTISEPSIS  IN  SURGERY.  151 

Where  the  means  at  hand  will  permit,  the  main  lines  of 
waste,  soil,  and  vent  pipes  should  be  of  galvanized  wrought 
iron  screwed  together,  rather  than  the  usual  form  of  cast 
iron  with  lead  calked  joints  which  can  not  be  depended 
upon  to  remain  tight. 

The  principle  of  placing  all  bathrooms,  water-closets, 
etc.,  in  a  pavilion  separate  from  the  hospital  wards  is  good. 
In  such  an  arrangement  the  pavilion  is  reached  by  short, 
connecting  corridors  having  openings  on  both  sides  so  that  a 
cross  current  of  fresh  air  is  always  maintained  between  the 
main  building  and  the  pavilion  containing  the  plumbing. 
This  separation,  of  course,  requires  space  and  money,  and 
may  not  always  be  had ;  some  modifications  costing  less 
may,  however,  be  within  reach,  and  the  nearer  the  ap- 
proach to  the  ideal  the  more  satisfactory  will  be  the  result. 

Whether  the  plumbing  fixtures  are  contained  in  a  sepa- 
rate pavilion  or  inclosed  in  the  main  building,  the  main  ver- 
tical lines  of  piping  should  be  placed  in  a  specially  arranged 
vertical  shaft  extending  from  the  house  drain  at  bottom  up 
to  and  above  the  roof.  This  shaft  should  be  large  enough 
to  permit  of  the  proper  spacing  and  arrangement  of  all 
pipes,  and  for  a  man  to  conveiiieutly  reach  all  connec- 
tions and  branches  to  fixtures.  The  branches  to  fixtures 
should  be  run  in  this  shaft  so  that  there  would  be  only  the 
supply  cocks  and  trap  visible  in  the  room.  If  impossible 
to  reach  a  fixture  by  a  branch  in  the  shaft,  then  only  so 
much  as  is  necessary  should  be  run  on  the  ceiling  of  the 
room  below  so  as  to  avoid  horizontal  pipes  at  or  near  the 
floor,  as  these  present  almost  insurmountable  obstacles  to 
thorough  cleaning. 

The  vertical  shaft  containing  the  main  pipes  should  have 
open  iron  gratings  at  floor  levels  instead  of  solid  floors,  and 
should  have  no  openings  into  it  except  a  small  "  manhole  " 
or  door  at  the  bottom,  the  various  floor  levels  being  reached 
by  an  iron  ladder  built  in  the  shaft  itself.  To  complete  the 
scheme  the  shaft  should  be  heated  so  as  to  produce  a  strong 
upward  draught  in  the  soil,  waste,  and  vent  pipes  and  their 
11 


152  ELECTRO-H^MOSTASIS  IN  OPERATIVE   SURGERY. 

branches,  so  as  to  quickly  and  thoroughly  oxidize  any  or- 
ganic matter  adhering  to  their  sides. 

Floor  drains  should  be  avoided  as  far  as  possible,  and 
where  necessary  should  discharge  into  a  water-supplied  sink 
placed  in  a  shaft  as  already  described  or  in  a  room  below. 
The  sink  being  connected  to  the  waste  ]3ipe  in  the  same 
manner  as  other  fixtures,  the  outlet  in  the  floor  should  have 
a  cover  which  could  not  be  closed  until  a  cap  had  been 
screwed  down  over  the  waste,  thus  insuring  complete  isola- 
tion of  the  floor  drain  from  the  main  drains  and  wastes. 

The  sink  or  basin  in  an  operating  room  should  discharge 
in  the  same  manner  as  the  floor  drains,  so  as  to  have  no  di- 
rect connection  with  the  drainage  system. 

Polished  brass  or  nickel-plated  piping  requires  too  much 
time  in  cleaning  for  general  use  ;  unpolished  brass  pipe  and 
fittings,  painted  with  enamel  paint,  will  be  found  more  ser- 
viceable where  economy  of  labor  is  to  be  considered. 

Much  attention  and  care  is  necessary  to  make  water- 
tight connections  where  pipes  pass  through  tile  or  similar 
flooring,  especially  hot- water  pipes,  so  that  the  floors  may  be 
thoroughly  washed  without  leaking. 

HEATING    AND    VENTILATION    OF   HOSPITALS 

Possibly  no  part  of  hospital  construction  has  received 
more  attention  than  the  heating  and  ventilating.  The 
amount  of  fresh  air  required  for  each  patient  and  its  tem- 
perature have  both  been  satisfactorily  determined ;  the  prac- 
tical operation  of  supplying  the  air,  warming  it,  and  causing 
it  to  circulate  completely  throughout  the  whole  of  each 
room  is  beset  with  many  difficulties.  For  ordinary  work  it 
has  been  found  more  desirable  to  divide  the  problem  into 
two  distinct  parts,  one  the  heating  and  the  other  the  venti- 
lating. In  this  method  the  air  is  heated,  by  large  heating 
stacks  located  in  the  lower  part  of  the  building,  to  the  tem- 
perature desired  for  the  room,  say  70°  F.,  the  air  being  at 
this  comparatively  low  temperature  can  not  counteract  the 
cooling  effect  of  doors  and  windows  and  walls ;  to  do  this 


ASEPSIS  AND  ANTISEPSIS  IN  SURGERY.  153 

direct  radiators  are  placed  at  proper  points  in  tlie  rooms  to 
be  heated.  This  system  works  well,  but  the  direct  radi- 
ators in  the  rooms  rapidly  collect  dust  and  are  very  difficult 
to  clean.  A  more  satisfactory  but  a  more  expensive  method 
consists  in  heating  the  ^vhole  volume  of  air,  at  a  central 
point  or  station,  to  nearly  the  temperature  required  by  the 
various  rooms,  the  air  passing  along  main  ducts  or  con- 
duits to  the  vertical  flues  leading  to  the  rooms.  At  the 
base  of  each  vertical  flue  is  placed  a  separate  and  inde- 
pendent stack  or  indirect  radiator,  w^hich  further  heats  the 
air  to  the  temperature  required.  In  this  method,  every 
room  governing  its  own  temperature,  the  air  may  be  suffi- 
ciently warmed  to  overcome  the  cooling  effect  of  outside 
walls,  doors,  and  windows.  This  method  would  probably 
be  as  near  an  ideal  scheme  as  possible  to  provide. 

The  matter  of  automatic  control  of  heating  surfaces, 
such  as  stacks  and  radiators,  has  been  brought  very  near 
perfection  by  vaiious  forms  of  thermostatic  valves  operated 
by  the  temperature  of  the  rooms  they  control.  These  valves 
have  been  found  to  act  with  great  certainty,  so  that  the 
temperature  may  be  maintained  within  a  variation  of  a 
degree  above  or  below  the  required  temperature.  The 
thermostatic  valves  are  applicable  to  both  systems  described 
above,  and  as  it  eliminates  the  necessity  of  depending  upon 
attendants  to  operate  hand  valves,  the  temperature  is  more 
uniformly  maintained. 

In  the  best  work  the  air  is  filtered  through  screens  of 
gauze  before  entering  the  heating  chambers.  These  screens 
take  out  nearly  all  the  dust,  so  that  the  air  in  the  flues  and 
ducts  is  practically  clean.  A  fiu-ther  application  of  the 
screen  system  to  special  rooms,  such  as  operating  rooms, 
would  be  of  great  advantage. 

It  has  been  found  that  by  passing  the  air  through  screens 
formed  of  sterilized  cotton  batting  it  is  not  only  cleaned  of 
dust  but  is  also  sterilized,  and  the  advantages  of  sterilized 
air  in  an  operating  room  is  of  course  obvious.  This  steri- 
lizing is  readily  accomplished  by  arranging  a  set  of  cotton- 


154  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

batting  screens  in  the  flue  leading  to  the  room  where  ster- 
ilized air  is  required,  the  screens  being  made  somewhat  upon 
the  principle  of  a  photographer's  "  plate-holder,"  allowing 
the  frame  to  be  withdrawn  for  the  purpose  of  changing  the 
cotton  fi'om  time  to  time,  the  frame  sliding  in  and  out  of  a 
trunk  or  other  device  built  in  the  flue  in  very  much  the 
same  manner  as  a  plate-holder  is  put  into  a  camera. 

The  increased  resistance  offered  by  the  cotton  would 
of  course  require  a  stronger  draught  or  pressui'e  of  air  in 
the  flue,  but  there  is  nothins;  in  the  scheme  which  would 
make  it  impracticable. 

Direct-indirect  radiation  should  never  be  used  where  an 
indirect  system  can  possibly  be  aiforded. 

The  direct-indirect  scheme,  as  is  well  known,  consists  of 
a  radiator  -with  a  "  box  base,"  into  which  air  is  admitted 
through  an  opening  in  the  wall  directly  behind  it,  the  air 
entering  the  base  of  the  radiator  passes  over  it,  and,  be- 
coming heated,  enters  the  room.  It  is  impossible  to  prop- 
erly filter  the  air  with  this  method,  and  it  is  also  impossible 
to  properly  regulate  the  temperature  or  supply.  As  a  mat- 
ter of  economy  it  may  answer  for  some  small  unimportant 
rooms  in  case  an  outlet  flue  is  provided  leading  to  a  main 
exhaust  stack  or  duct. 

Storerooms,  clothesroom,  and  closets  should  not  be  over- 
looked, but  should  have  as  thorough  ventilation  as  any  other 
rooms.     This  is  often  neglected. 

Lavatories  and  rooms  containing  water-closets  and 
urinals  should  be  ventilated  throuo-h  the  fixtures — that  is, 
the  air  should  be  drawn  out  of  the  room  through  the  bowls 
of  the  fixtures  themselves  and  conveyed  by  separate  flues 
to  the  top  of  the  building.  In  this  way  all  odor  may  be 
entu'ely  eliminated  from  these  rooms. 

Xo  building  can  be  thoroughly  ventilated  without  the 
use  of  a  mechanical  system,  including  the  use  of  fans  or 
blowers.  Generally,  it  ^vill  be  found  best  to  provide  two 
sets  of  fans,  one  to  force  air  into  the  rooms  and  the  other 
to  draw  it  out. 


ASEPSIS  AND  ANTISEPSIS  IN  SURGERY.  155 

All  rooms  should  be  under  a  slight  pressure,  so  that  the 
warm  air  of  the  room  will  be  escaping  through  the  cracks 
and  openings  around  doors  and  windows  instead  of  the 
cold  ail*  outside  leaking  in  and  causing  draughts. 

Double  sash  or  double  glazing  will  be  found  of  great 
service  in  making  the  temperature  of  a  room  more  uniform, 
as  well  as  reducing  the  consumption  of  fuel.  It  will  also 
have  the  effect  of  reducing  the  cost  of  the  whole  plant,  as 
the  glass  in  windows  is  by  far  the  most  effective  medium 
in  cooling  the  air,  and  is  a  very  important  factor  in  deter- 
mining and  proportioning  the  heating  surfaces  and  other 
parts  of  the  heating  system. 

The  system  of  exhaust  flues  and  ducts  is  quite  as  im- 
portant as  the  supply,  and  should  be  as  carefully  develoj)ed. 

The  location  of  registers  in  the  rooms  is  also  a  very  im- 
portant item  in  securing  a  complete  cii'culation  of  air  in  all 
parts  of  the  room.  ExjDerience  has  demonstrated  that  they 
should  both  be  placed  on  the  same  side  of  a  room  and  near 
together,  the  supply  being  about  eight  feet  above  the  floor 
and  the  exhaust  at  or  near  the  floor  level. 

In  furnishing  hospital  rooms  and  wards  the  same  rules 
should  be  followed  as  in  the  construction  of  the  building. 
The  furniture  should  be  such  as  mil  not  lodge  dirt  or 
absorb  the  germs  of  disease.  Simplicity  in  design  and 
construction  guards  against  the  accumulation  of  dust  and 
dirt,  and  the  material  used  should  be  impenetrable  as  far 
as  possible.  .Metal  bedsteads  and  washstands  are  the  best 
in  use  at  the  present  time  when  well  plated.  When  these 
expensive  articles  can  not  be  afforded,  white  enamel  iron 
answers  as  well.  Bureaus  and  cabinets  should  not  be  used 
as  a  rule ;  but  if  permitted,  to  please  lady  patients,  they 
should  be  severely  plain,  and  enameled  within  and  without. 
Such  fui'niture  is  easily  kept  clean  all  the  time,  and  can  be 
sterilized  when  the  room  is  treated  by  disinfection  in  the 
way  to  be  hereafter  described. 


CHAPTEE  XYI 

ASEPSIS    AISTD    ANTISEPSIS    (cOISTTINIJEd) 

AccoEDijsTG  to  my  observations  most  of  the  imperfec- 
tions in  carrying  out  aseptic  methods  in  surgery  occur  in 
admission  of  patients  and  the  management  of  their  clothing. 
To  guard  against  all  possible  infection  from  without  the 
hospital  requires  a  thorough  disinfection  of  everything 
which  conges  into  the  building.  Patients  do  not  always 
know  that  they  have  been  exposed  to  contagious  disease ; 
sometimes  they  will  not  admit  the  exposure  if  they  do  know 
of  it.  One  may  not  disregard  this  possible  danger  of  pa- 
tients bringing  from  infected  parts  of  the  city  sepsis  and 
infectious  diseases.  The  only  safe  course  is  to  insist  upon 
the  sterilization  of  every  new  patient  immediately  upon 
her  arrival  and  the  disinfection  of  all  her  clothing. 

The  method  which  I  practice  is  as  follows :  The  patient 
is  at  ohce  taken  to  the  dressing  room  adjoining  the  bath- 
room, where  her  clothing  is  removed  and  put  into  a  clean 
bag  and  sent  to  the  sterilizer.  She  leaves  her  street  costume 
here  and  is  conducted  to  the  bathroom  to  receive  an  ammo- 
nia bath,  and  then  dressed  in  a  full  change  of  clothing, 
which  had  been  sent  to  the  hospital  the  previous  day  and 
sterilized.  All  her  clothing  and  everything  which  she  has 
brought  with  her  is  sterilized  by  fonnaldehyde  before  being 
taken  to  her  room.  By  this  means  the  surgeon  -will  assure 
himself  that  his  new  patient  has  at  least  rightly  begun  her 
hospital  life. 

The  Preparation  of  a  Patient  for  all  Major  Operations. 
— The  previous  night  she  receives  a  full  ammonia  bath,  in 
giving  which  the  nurse  is  careful  to  clean  all  folds  of  the 

156 


ASEPSIS  AND   ANTISEPSIS  IN  SURGERY.  157 

skin.  It  is  to  be  kept  in  mind  that  the  nurse  in  charge  of 
the  bath  must  herself  be  clean.  Thorough  scrubbing 
should  be  practiced  and  then  the  body  rinsed  off  with 
boiled  water.  The  head  should  be  shampooed  with  alcohol 
and  quickly  dried.  This  having  been  accomplished,  the 
patient  is  dressed  in  sterilized  under  and  night  clothes  and 
then  put  into  the  bed  newly  made  up  with  sterilized  bedding 
and  bedclothes.  A  further  cleansing  is  now  given  the 
whole  abdomen  in  cases  of  abdominal  section ;  it  is  thor- 
oughly scrubbed  with  soap  and  water,  then  washed  off  with 
a  one-in-two-thousand  bichloride  solution ;  finally,  a  bichlo- 
ride compress  (one  in  one  thousand)  and  a  clean  binder  are 
put  on.  The  next  morning  this  last  cleansing  process  is 
repeated  and  a  new  compress  and  binder  are  applied.  Now 
that  the  patient  is  clean,  the  utmost  care  must  be  exercised 
to  protect  her  against  contamination.  She  must  be  con- 
veyed to  the  ansBsthetizing  room  in  a  clean  carriage  or 
stretcher  by  clean  attendants.  The  anaesthetist  and  the  at- 
tending nurses  are  dressed  in  clean  garments.  The  anaes- 
thetizing instruments  have  been  cleaned  the  same  as  the 
instruments  for  the  operation.  If  the  narcosis  is  not  given 
while  the  patient  remains  in  her  carriage,  the  couch  or  table 
on  which  she  is  placed  is  to  be  covered  with  sterilized  ma- 
terial. As  soon  as  the  patient  does  not  recognize  her  sur- 
roundings she  is  finally  prepared  for  the  operation  by 
scrubbing  the  abdomen  with  soap  and  water,  the  hypogas- 
trium  is  then  shaved  with  a  sterilized  razor,  dried  and 
bathed  first  in  alcohol,  then  ether,  and  finally  bichloride 
solution,  one  in  one  thousand.  The  umbilicus  is  covered 
with  collodion,  in  case  it  is  not  to  be  incised ;  a  clean  com- 
press and  a  new  binder  complete  all  and  the  patient  is  ready 
to  be  taken  into  the  operation. 

The  room  used  for  operations  is  twice  cleaned,  once  just 
after  the  preceding  operation  and  again  in  preparation  for 
the  next  one.  Everything  which  is  needed  for  the  opera- 
tion, except  instruments,  is  brought  in ;  then  the  formalde- 
hyde is  introduced,  and  the  room  sealed  for  five  hours. 


158  ELECTRO-H^MOSTASTS   IX   OPERATIVE   SURGERY. 

Blunt  instruments  are  sterilized  by  exposure  in  live 
steam  for  fifteen  minutes ;  edged  instruments  are  immersed 
in  alcohol  (ninety -five  per  cent)  for  ten  minutes.  Of  late 
instruments  are  sterilized  in  formaldehyde ;  and  I  believe  it 
will  prove  to  be  the  best  method.  When  needed  they  are 
placed  into  the  trays  and  covered  with  hot  carbolized  solu- 
tion. Formula :  Carbolic  acid,  three  per  cent ;  glycerin, 
twentv-two  per  cent ;  water,  seventy-five  per  cent.  Xatu- 
ral  sponges  are  washed  for  twenty-four  hours  in  Javell 
water,  the  grit  is  taken  out,  and  then  they  are  washed  in 
sterilized  water ;  they  are  preserved  in  five-per-cent  carbolic 
solution.  A  careful  rinsing  in  running  sterilized  water 
prepares  them  for  immediate  use.  They  should  not  be 
used  a  second  time  in  abdominal  work.  Gauze  sponges, 
the  towels,  binders,  and  gowns  are  cleansed  by  the  ordinar}" 
steam  apparatus.  The  primary  gauze  dressing  is  prepared 
in  quantities  by  saturating  it  in  a  solution  of  carbolic  acid, 
one  paii:  to  glycerin  eight  parts.  It  is  always  ready,  and 
requires  but  to  have  the  excess  of  the  solution  rung  out  of 
it  with  a  sterilized  towel  immediately  before  using. 

The  suture  material  used  is  the  ordinary  braided  silk, 
which  is  sterilized  perfectly  by  boiling  in  salicylated  wax 
for  twenty  hours,  in  five-hour  fractions,  with  an  hour  inter- 
val. Suture  material  prepared  in  this  way  is  perfectly 
sterile  and  can  be  kept  so  for  any  length  of  time.  More 
than  that,  it  ^vill  remain  sterile  in  the  tissues  as  long  as 
silver  wii'e.  This  was  demonstrated  by  both  laboratoiy 
and  clinical  experiments  many  years  ago. 

Cleansing  and  sterilizing  the  hands  has  always  been  one 
of  the  subjects  which  claim  the  most  careful  attention  of 
surgeons.  Even  at  the  present  time  all  methods,  and  they 
are  many,  are  questioned  regarding  their  efiSciency  or  prac- 
tical application.  "Without  discussing  the  subject  I  shall 
give  the  methods  employed  in  my  own  practice  and  which 
have  given  the  best  results  in  re^rard  to  both  the  patient 
and  the  operator. 

The  method  employed  is  as  as  follovzs  :  Soft  srreen  ster- 


ASEPSIS  AND  ANTISEPSIS  IN  SURGERY.  159 

ile  soap  is  used  with  a  sterile  brush  and  running  water  that 
has  been  sterilized  by  boiling  or  distillation.  The  soap  is 
thoroughly  applied  with  the  brush,  then  washed  oi£  in 
the  stream  of  water.  This  process  is  repeated  four  or  five 
times,  according  to  the  condition  of  the  hands.  The  water 
is  made  to  play  with  force  upon  all  parts  of  the  hands  and 
arms  until  all  particles  of  the  soap  and  dirt  are  washed  off. 
Finally,  the  liands  are  placed  in  a  solution  of  carbolic  acid 
three  per  cent,  glycerin  twenty-two  per  cent,  and  water 
seventy-five  per  cent,  and  scrubbed  or  rubbed  in  with  a 
brush.  The  excess  of  the  solution  is  wiped  oif  with  a  clean 
towel,  and  they  are  ready  for  use.  This  is  sufiicient  treat- 
ment of  the  hands,  unless  the  surgeon  has  been  contaminated 
by  examining  or  operating  upon  septic  cases ;  then  a  more 
careful  disinfection  is  necessary.  In  such  conditions  of  the 
hands  more  prolonged  washing  is  employed,  and  then  they 
are  thoroughly  anointed  with  carbolic  acid  pure  one  part  and 
glycerin  seven  or  eight  parts.  This  is  applied  to  the  hands 
and  arms  and  rubbed  in  with  a  soft,  clean  brush  and 
allowed  to  remain  about  five  minutes.  It  is  then  rapidly 
washed  off  with  a  strong  stream  of  rapid-running  water. 
The  reason  for  doing  this  quickly  is  that  the  added  water 
develops  the  caustic  properties  of  the  carbolic  acid  so  that 
it  will  injure  the  skin  if  permitted  to  remain  in  contact 
with  it. 

The  advantages  which  this  glycerin  and  carbolic-acid 
solution  has  is  that  the  glycerin  neutralizes  the  caustic 
properties  of  the  acid  and  does  not  diminish  its  power  as  a 
germicide.  Furthermore,  it  keeps  the  hands  in  good  condi- 
tion. I  am  quite  confident  that  this  is  a  most  satisfactory 
way  of  treating  the  hands  so  far  as  sterilizing  them,  not  on 
the  surface  only  but  deep  into  the  cuticle  as  far  as  germs 
go.  The  mercuric  solutions  which  I  formerly  used  hard- 
ened the  skin  and  left  living  organisms  beneath  the  crust 
of  sterilized  tissue.  This  hardened  epithelium  became 
softened  in  abdominal  work  and  set  free  the  living  germs 
that  escaped  the  sterilizing.     That  is  one  of  the  imperfec- 


160  ELECTRO-H.EMOSTASIS  IN  OPERATIVE  SURGERY. 

tions  of  the  usual  way  of  cleaning  tlie  hands,  which  has 
been  pointed  out,  and  has  driven  some  surgeons  to  the  use 
of  gloves  while  operating. 

I  prefer  to  wear  gloves  when  examining  doubtful  cases, 
dressing  wounds,  or  handling  pathological  specimens,  and 
so  keep  the  hands  free  from  infecting  germs  that  can  not  be 
destroyed  by  the  method  of  cleansing  which  I  practice,  or 
any  other  method  known  to  me. 

There  is  but  one  objection  to  the  carbolic  and  glycerin 
solution,  and  that  is  the  expense,  but  that  is  hardly  worth 
naming  in  view  of  the  advantages  given  by  its  use. 

The  subject  of  room  disinfection,  which  has  been  far 
from  satisfactory  in  the  past,  has  been  greatly  improved  of 
late.  Indeed,  I  feel  sure  that  the  recent  improvements  in 
this  direction  meet  the  requirements. 

The  recent  work  of  Ezra  H.  Wilson,  M.  D.,  is  the  most 
perfect  that  is  known  to  me ;  and  I  give  here,  by  permission, 
his  essay  on  this  subject : 

The  requirements  to  be  met  in  a  proj^er  disinfection  of 
an  apartment  in  which  there  has  been  infectious  diseases  are  : 

First.  Absolute  disinfection ;  by  that  is  meant  the 
destruction  of  all  infectious  material. 

Second.  Ease  and  rapidity  in  application. 

Thii'd.  Economy. 

Fourth,  The  least  possible  damage  to  disinfected  goods. 

The  best  disinfectant  applicable  to  infected  goods  such 
as  wearing  apparel,  bedding,  etc.,  is  heat  in  the  form  of 
steam,  and  it  is  safe  to  say  that  up  to  the  present  time  no 
substitute  has  been  found  which  will  disinfect  so  thoroughly, 
rapidly,  and  economically  as  steam.  The  objections  to  its 
universal  application  are,  that  it  can  not  be  applied  in  the 
disinfection  of  apartments  (walls,  floors,  ceilings,  etc.),  and 
that  certain  cheap  grades  of  colored  goods  are  often  injured 
by  it.  The  disinfection  of  apartments  by  the  mechanical 
process  of  rubbing  and  scrubbing  with  disinfecting  solutions, 
while  veiy  thorough,  is  tedious,  expensive,  and  often  dam- 
aging to  painted  and  frescoed  walls  and  ceilings. 

If,  therefore,  an  agent  can  be  found  which  can  be  used 
for  the  disinfection  of  apartments  which  will  be  an  efficient 


ASEPSIS  AND  ANTISEPSIS  IN  SURaERY.  161 

germicide  and  not  cause  any  damage,  it  is  very  desirable  to 
investigate  it.  Such  an  agent  we  believe  we  have  in  for- 
maldehyde gas,  used  in  a  proper  manner  and  in  proper 
amounts.  The  original  method  was  to  produce  the  gas  by 
the  oxidation  of  methyl  alcohol  in  the  presence  of  incan- 
descent platinum  or  platinized  asbestos,  and  that  is  the 
method  now  used  in  the  many  lamps  now  in  the  market, 
and  for  which  extravagant  claims  are  made.  There  are 
many  objections  to  these  lamps.  In  the  first  place,  and 
what  is  most  important,  they  do  not  produce  enough  of  the 
gas  to  be  of  any  value.  Second,  they  involve  the  use  of 
an  inflammable  and  explosive  compound,  the  methyl  alcohol, 
in  proximity  to  an  open  flame.  Third,  they  have  to  be 
lighted  and  shut  up  in  a  room  where  they  are  hidden  from 
observation.  Fourth,  it  is  impossible  in  practice  to  regulate 
the  lamp  so  as  to  get  the  maximum  amount  of  gas,  and  so 
to  allow  of  the  escape  of  unoxidized  methyl  alcohol  vapor. 

Roux,  Baudet,  Trillat,  and  others  devised  a  method  of 
evolving  formaldehyde  gas  from  formalin.  Formalin  or 
formol  is  a  saturated  (forty  per  cent)  solution  of  the  gas 
in  water.  If  a  quantity  of  formalin  is  mixed  with  an  equal 
quantity  of  a  five-  to  ten-per-cent  solution  of  calcium  chloride, 
it  will  be  found  that  the  boiling  point  of  the  mixture  is 
considerably  above  100°  F.  (103°  to  106°),  and  the  most 
favorable  temperature  for  evolving  formaldehyde  gas  is 
between  95°  and  100°  F.  Thus  nearly  all  the  gas  is  evolved 
before  the  mixture  is  giving  off  steam.  Moreover,  it  pre- 
vents the  polymerization  of  the  gas  into  trioxymethelene. 

I  will  now  describe  an  apparatus  for  carrying  out  this 
process. 

PARTIAL    DESCRIPTION    OF  AND   DIRECTIONS    FOR    THE    USE    OF 
THE   TRILLAT   AUTOCLAVE 

The  Apparatus  is  pached  in  Tivo  Cases. 

Autoclave  Case. — Containing  autoclave  with  gauge; 
thermometer ;  two  handles  and  a  tin  case  containing  two 
outlet  tubes  and  a  wire  to  clean  same. 

Case  of  Accessories. — Special  lamp  and  small  can  con- 
taining alcohol  to  light  same ;  copper  can  for  the  formo- 
chloral ;  tin  can  for  kerosene ;  cotton  wadding  for  stuflfing 
cracks  in  windows,  doors,  etc. ;  pair  of  spectacles  to  protect 
eyes. 


162  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

Trillat  Autoclave. — The  vessel  of  the  apparatus  is  made 
of  heavy  copper  which  is  silver-lined  and  has  a  capacity  of 
about  one  and  one  half  gallons.  The  remainder  of  the 
apparatus  is  mostly  brass,  highly  polished  and  carefully 
finished. 

The  cover  of  the  autoclave,  which  rests  on  a  rubber 
band  so  that  it  can  be  tightened  to  avoid  any  leakage,  is 
equipped  with  a  pressure  gauge,  a  sleeve  in  which  the  ther- 
mometer is  placed  and  a  stopcock  by  which  one  regulates 
the  escape  of  formaldehyde  gas. 

Lamp, — The  apparatus  is  heated  by  means  of  a  special 
lamp,  the  flame  of  which  is  fed  by  kerosene  vapors.  By  a 
small  screw  one  can  regulate  the  heat,  and  by  using  the 
pump  occasionally  one  can  increase  the  heat. 

Formocliloral  is  a  saturated  solution  of  formic  aldehyde 
and  a  neutral  or  indifferent  mineral  salt  and  absolutely  free 
fi'om  methyl  alcohol.  When  heated  under  pressure,  formal- 
dehyde vapors  are  evolved  in  a  non-polymerized  condition. 

Before  putting  the  formochloral  into  the  autoclave,  it 
should  be  well  mixed  so  as  to  distribute  any  precipitate 
which  may  be  in  the  same.  This  deposit  is  not  an  im- 
purity, but  on  the  contrary  is  one  of  the  essential  parts  of 
the  solution. 

Directions. — All  cracks  around  windows,  doors,  fire- 
places, etc.,  should  be  stuifed  to  reduce  the  possibility  of 
the  gas  escaping  as  far  as  possible. 

The  formochloral  is  put  into  the  autoclave,  which  should 
never  be  more  than  three  quarters  full,  about  one  gallon  or 
ten  pounds  by  weight  maximum.  The  minimum  should 
not  be  less  than  a  quart,  or  about  two  and  one  half  pounds 
by  weight  on  account  of  the  possibility  of  injuring  the  auto- 
clave. One  calculates  that  one  pound  of  formochloral  is 
sufficient  for  2,500  to  5,000  cubic  feet  of  air  space. 

When  tightening  the  cover,  one  should  screw  the  op- 
posite bolts  little  by  little  so  as  not  to  press  on  one  side  of 
the  rubber  band. 

The  apparatus  after  being  closed  is  placed  in  front  of 
the  door  of  the  room  that  is  to  be  disinfected  at  a  conven- 
ient height  so  that  the  stopcock  is  level  with  the  keyhole. 

Carefully  examine  the  outlet  tube  through  which  the 
formaldehyde  gas  is  allowed  to  escape  and  see  that  it  is 
free  from  any  obstructions.     Then  put  it  through  the  key- 


ASEPSIS   AND  ANTISEPSIS  IN  SURGERY.  163 

hole,  allowing  it  to  project  inside  of  the  room  from  about 
four  to  six  inches  ;  then  attach  it  to  the  autoclave  by  means 
of  the  screw  bolt  attached  to  the  same.  Put  the  thermome- 
ter in  place,  close  the  stopcock,  and  light  the  lamp. 

When  the  gauge  indicates  a  pressure  of  a  little  over  or 
about  three  atmospheres,  carefully  open  the  stopcock  little 
by  little,  otherwise,  should  it  be  opened  too  rapidly,  the 
liquid  in  the  autoclave  is  apt  to  force  itself  out  through 
the  tube  and  is  liable  to  produce  disagreeable  results,  and 
for  this  reason  it  is  well  to  take  the  precaution  of  removing 
the  furniture  and  to  cover  carpets  that  may  be  directly  in 
the  vicinity  of  where  the  outlet  tube  projects. 

One  knows  that  the  gas  flow  is  well  regulated  by  the 
very  gradual  falling  of  the  pressure  as  indicated  by  the 
gauge.  The  pressure  should  be  kept  as  near  as  possible 
between  two  and  three  atmospheres.  The  vaporization  can 
be  considered  finished  in  about  one  and  one  half  hours 
when  two  and  one  half  pounds  of  formochloral  is  used ; 
for  the  maximum  charge,  ten  pounds,  two  hours  sufiices 
ordinanly,  and  one  must  always  stop  the  operation  when 
the  thermometer  is  over  135°  and  the  pressure  is  below 
two  or  three  atmospheres.  When  the  operation  is  over 
the  outlet  tube  can  be  withdrawn  and  keyhole  stopped. 

It  is  preferable  to  allow  the  formaldehyde  gas  to  re- 
main as  long  as  possible,  but  from  three  to  four  hours'  con- 
tact is  sufficient  for  a  good  disinfection.  Afterward  it  is 
necessary  to  air  the  apartment.  To  do  this,  enter  rapidly, 
wearing  the  glasses  and,  without  breathing,  open  the  win- 
dow. One  half  hour  later,  one  can  without  inconvenience 
enter  the  room.  The  order  of  formaldehyde  can  be  neu- 
tralized more  rapidly  by  injecting  a  little  ammonia  into 
the  room. 

After  the  apparatus  is  cooled  remove  the  thermometer, 
take  off  the  cover  of  the  autoclave,  and  empty  the  residue, 
which  should  be  in  a  liquid  form.  Clean  with  water  and 
dry  with  a  linen  rag. 

It  will  be  seen  from  the  experiment  that  the  organisms 
protected  by  the  folds  of  blanket  were  not  killed,  and  this 
brings  up  another  consideration,  namely,  that  of  penetra- 
tion. No  matter  how  valuable  this  agent  in  a  free  state 
may  be  as  a  disinfector  of  superficially  infected  areas,  such 
as  walls,  floors,  and  ceilings,  it  must  be  admitted  that  its 


164 


ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 


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-:i    ::    ::    ::     Oh 


£S  S 


-ai 


"•■'  s  s 

Q    ^  o3 

CL,  to  to 

CO  (U  (U 

C  .  : 

03  (D 


2   23  '=-■   fan  '""^'t,   to   to   2  '^   «=   "   hn  hr 


fq  m  pq  oQ  PQ  m  pq  pq  pq  m  m  PQ  cq  ^  S 


ASEPSIS  AND   ANTISEPSIS  IN  SURGERY. 


165 


power  of  penetration  is  not  great,  and  although  somewhat 
foreign  to  the  subject  of  this  paper,  I  will  describe  some 
experiments  which  were  made  to  test  this  matter  of  pene- 
tration. These  were  made  at  the  City  Disinfecting  Station 
by  R.  B.  F.  Randolph,  assistant  bacteriologist. 


Table  1 


No. 

Culture. 

1 

Anthrax. . . : . . 

2 

" 

3 
4 

Typhoid 

S.  P.  A 

5 

Anthrax 

6 

7 

Diphtheria  .  . . 
S.  P.  A 

8 
9 

Typhoid 

Anthrax 

10 
11 

Diphtheria  . . . 
S.  P.  A 

13 
13 

Typhoid 

Anthrax 

14 
15 

Diphtheria  .  .  . 
S.  P.  A 

16 
17 

Typhoid  .... 
Anthrax 

18 
19 

Diphtheria  . . . 
S.  P.  A 

20 

21 

Typhoid 

Anthrax 

22 
23 

Diphtheria  . . . 
S.  P.  A 

24 
25 

Typhoid 

Anthrax 

26 

27 

Diphtheria  . .  . 
S.  P.  A 

28 
29 

Typhoid 

Anthrax 

Location. 


Inside  a  straw  mattress. 


Folded  in  the  middle  of  an  excelsior  mattress. 


Between  mattress  and  feather  bed. 


Surrounded  by  two  layers  of  blankets. 


'   one  layer  of  blanket. 


'   four  layers  of  blankets. 


eight     " 


Exposed  on  top  of  the  pile  of  goods. 


Result. 


Lived. 


Died. 


Lived. 
Died. 


Lived. 

Died. 
Lived. 

Died. 


Experiment  No.  2 

A  Trillat  autoclave  was  so  arranged  that  a  stream  of 
formaldehyde  gas  could  be  forced  into  the  inner  chamber  of 
the  disinfecting  oven.  Sterile  silk  threads  were  immersed  in 
cultures  of  sporulating  anthrax,  B.  typhosus,  B.  diphtherise, 
and  staphylococcus  pyogenes  aureus,  and  allowed  to  dry  at 
ordinary  temperatures.  When  dry  they  were  inclosed  in 
sterile  filter-paper  envelopes  and  arranged  as  described  in 
Table  1. 

The  conditions  of  the  experiment  were  as  follows : 

Quantity  of  formochloral  used,  1,250  c.  c. 

Capacity  of  the  chamber,  340  cubic  feet. 


166  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

Vacuum  at  the  beginning  of  tlie  test,  14  inches  of 
mercury. 

Vacuum  after  the  admission  of  the  formaldehyde,  11 
inches. 

Gas  was  run  in  for  thirty  minutes. 

After  the  gas  had  ceased  to  flow,  air  was  admitted  until 
the  o'auo'e  stood  at  zero. 

One  hour  after  the  gas  was  shut  off  the  chamber  was 
twice  exhausted  and  filled  with  air. 

The  chamber  was  opened  at  10  a.  m.  the  following  day. 

There  was  a  slight  odor  of  formaldehyde,  but  not  enough 
to  prevent  a  man  from  going  in  immediately.  About  two 
gallons  of  water  smelling  strongly  of  the  gas  was  found  on 
the  floor  of  the  chamber.    The  goods  were  dry  and  uninjured. 

It  will  be  seen  that  the  disinfection  was  far  from  com- 
plete, the  anthrax  not  being  killed  except  in  one  instance, 
and  the  other  organisms  in  the  more  protected  portions  of 
the  pile  not  being  affected.  This  lack  of  penetration,  how- 
ever, can  be  partially  accounted  for.  The  air  admitted  to 
the  chamber  immediately  after  the  gas  was  shut  off  was 
taken  through  the  sewer  outlet,  and  in  doing  this  the  con- 
tents of  the  trap  were  sucked  up  into  the  chamber  and 
possibly  dissolved,  and  thus  rendered  inoperative  a  large 
amount  of  the  gas. 

It  was  thought  that  a  greater  and  more  uniform  degree 
of  penetration  could  be  secured  by  slightly  heating  the 
chamber,  inasmuch  as  the  diffusion  power  of  a  gas  is 
largely  influenced  by  its  temperature.  The  following  ex- 
periment was  therefore  made : 

The  formaldehyde  was  generated  in  an  autoclave  built 
for  that  i^urpose  by  the  Kny-Scheerer  Co,  It  consisted  of 
a  copper  boiler  nickeled  inside  and  out  and  provided  with 
a  water  gauge,  safety  valve,  thermometer,  and  exit  tubes  for 
the  gas  evolved.  Heat  was  produced  by  a  triple  "Piis- 
Hius  "  oil  burner.  The  apparatus  was  connected  "with  the 
disinfecting  chamber  by  a  rubber  tube  which  connected 
with  a  small  iron  pipe  entering  the  chamber  at  the  top. 
The  formaldehyde  was  generated  from  a  mixture  of  Kny- 
Scheerer  formalin  38.7  per  cent  of  CHoO.  The  mixture 
was  made  u])  as  follows  : 

Formalin 1,350  c.  c. 

Calcium  chloride  (anhydrous) 200  grs. 

Water  to  make  up  to 4,000  c.  c. 


ASEPSIS  AND  ANTISEPSIS  IN   SURGERY. 


167 


The  determination  of  formaldehyde  was  made  by  the 
ammonia  method  as  given  by  Struver  (Zeit.  f.  Hyg.,  Bd. 

XXV,  Heft  2).  -,      .      T     V     ^     1.     1.  +1. 

All  determinations  were  made    m  duplicate    by   botn 
gravimetric  and  volumetric  methods.     It  would  have_  been 
advisable  to  determine  the  amount  of  mythyl  alcohol  m  the 
formalin,  as  this  reacts  with  formaldehyde  at  the  tempera- 
ture of  the  operation,  giving  methylal,  a  substance  havmg 
little  or  no  disinfecting  action.     Any  methyl  alcohol  pres- 
ent   therefore,  diminishes  the    efficiency  of    the  iormahn. 
No'  satisfactory  method  of  determining  methyl  alcohol  m 
such  a  mixture  has  yet   been  devised,  and  the  results  ot 
this  experiment    are  therefore  subject  to  a  correction  on 
this  account.     We  have  been  assured  by  the  manuiacturer 
of  the  formalin  used,  however,  that  it  contains  less  than 
one  per  cent  of  methyl  alcohol,  and  no  serious  error  wdl 
be  made  by  neglecting  it.  -,  n  •     ^        ^ 

Silk  threads  were  soaked  for  several  hours  m  twenty- 
four-hour  cultures  of  the  bacteria  used,  and  dried  at  room 
temperatures.  These  threads  were  then  inclosed  m  sterile 
filter-paper  envelopes  as  in  the  previous  experiment,  and 
were  aiTanged  as  shown  in  Table  2,  which  also  shows  the 
result  of  the  experiment. 

Table  2 


Organism  used. 


Location. 


Diphtheria 

Typhoid 

Anthrax  spores 

Staph,  pyogenes  aureus  . 

Diphtheria 

Typhoid 

Anthrax  spores 

Staph,  pyogenes  aureus , 

Diphtheria 

Typhoid 

Anthrax  spores 

Staph,  pyogenes  aureus 

Diphtheria 

Typhoid 

Anthrax  spores 

Staph,  pyogenes  aureus 


Within  a  folded  mattress, 

U  '^  " 

In  the  middle  of  a  folded  blanket. 
Between  two  folded  blankets. 
Exposed  on  top  of  pile. 


Result. 


Killed. 


The  pile  of  material  was  placed  on  the  truck  and  run 
into  the'  oven,  being  as  nearly  as  possible  m  tl^e  center  of 
the  chamber.      The  doors  were  then    tightly   closed   and 


12 


168  ELECTRO-H^MOSTASIS  IN  OPERATIVE  SURGERY. 

the  vacuum  pump  started,  and  steam  turned  into  the  outer 
jacket  in  order  to  heat  the  inner  chamber.  In  thirty 
minutes  a  vacuum  of  14.25  inches  was  obtained,  and  the 
temperature  of  the  inner  chamber  was  then  40*^  C.  In  the 
meantime  the  lamp  under  the  autoclave  had  been  lighted, 
and  the  pressure  raised  to  37.5  pounds.  The  valves  were 
then  opened  and  the  formaldehyde  gas  admitted  to  the 
chamber,  the  pressure  of  the  autoclave  being  kept  above 
30  pounds.  The  gas  was  allowed  to  flow  thirty  minutes 
and  was  then  shut  off,  the  vacuum  in  the  chamber  having 
fallen  to  10  inches  and  the  temperature  risen  to  49°  C. 
Air  was  then  admitted  to  the  chamber  through  the  safety 
valve  until  the  vacuum  was  reduced  to  zero.  The  temper- 
ature of  the  inner  chamber  was  then  raised  to  65°  C.  and 
kept  there  during  the  rest  of  the  experiment,  which  lasted 
altogether  an  hour  and  a  half.  At  the  expiration  of  this 
time  the  chamber  was  opened,  the  threads  in  the  enve- 
lopes were  removed  and  taken  to  the  laboratory,  where 
they  were  planted  in  sterile  broth  and  incubated  for  a 
week.  No  moist  cultures  were  used,  as  it  was  intended  to 
make  the  experiment  correspond  as  closely  as  possible  to 
actual  working  conditions,  and  in  practice  we  are  seldom 
called  upon  to  disinfect  articles  that  are  not  dry.  The  for- 
malin mixture  remaining  in  the  autoclave  was  carefully 
removed  and  measured.  It  amounted  to  2,300  c.  c.  and  con- 
tained 9.27  per  cent  of  formaldehyde,  corresponding  to 
213.2  grammes.  As  the  original  mixture  contained  500 
grammes  286.8  were  present  in  the  chamber,  and  as  the 
capacity  of  the  chamber  is  10,188  cubic  metres,  each  cubic 
metre  contains  28.11  grammes  of  CHgO.  This  corresponds 
to  a  volume  per  cent  of  1.93,  or,  in  round  numbers,  two  per 
cent. 

This  experiment  proves  that,  under  the  conditions 
adoped,  two  per  cent  is  sufficient  to  disinfect  anthrax 
spores  in  the  middle  of  a  mattress — a  very  severe  test — 
and,  on  this  account,  it  is  recommended  that  two  per  cent 
be  the  minimum  of  gas  allowed.  As  regards  the  temper- 
ature and  the  vacuum,  the  experiment  shows  that  a  temper- 
ature of  65°  C.  is  high  enough,  and  that  a  vacuum  of  at 
least  half  an  atmosphere  is  desirable. 

It  will  be  seen  that  the  temperature  exercises  a  marked 
effect  on  the  disinfection,  and  the  failure  of  the  first  experi- 


ASEPSIS  AND  ANTISEPSIS  IN  SURGERY.  159 

ment,  where  a  much  larger  percentage  of  gas  was  used, 
must  be  attributed  to  the  low  temperature  at  which  it  was 
conducted. 

This  method,  therefore,  gives  a  convenient  and  satisfac- 
tory disinfection  of  goods  that  would  certainly  be  injured, 
if  not  ruined,  by  the  use  of  steam. 

The  advantages  of  the  autoclave  over  the  lamps  are 
at  once  apparent : 

First.  It  produces  a  large  volume  of  the  gas. 

Second.  Rapidity  of  application. 

Third.  It  is  constantly  under  observation  and  located 
outside  the  room. 

Fourth.  No  damage  to  disinfected  goods. 

CLEANLINESS    IN    THE    CARE    OF    PATIENTS    AND    SICK    ROOMS 

The  older  methods  of  disposing  of  soiled  clothing, 
dressings,  and  discharges  were  most  objectionable.  Old  foul 
dressings  were  carried  from  the  halls,  some  of  them  to  the 
laundry,  to  be  washed  and  used  again.  Excrements  were 
carried  in  open  vessels  to  the  closets,  deposited  tbere,  and 
in  the  best-regulated  hospitals  or  homes  some  disinfectant 
poured  down  the  closet  every  time  it  was  used,  or  several 
times  a  day,  and  the  results  were  easily  to  be  imagined. 

The  methods  pursued  at  the  present  time  in  my  practice 
are  to  place  all  soiled  dressings  directly  on  their  removal  into 
a  vessel.  The  vessel  is  closed  witli  an  air-tight  rubber  cover 
and  taken  away  and  the  dressings  at  once  cremated.  The 
vessel  is  disinfected  at  once,  and  made  ready  for  further  use. 
Vessels  used  for  the  reception  of  excrement,  urinals  included, 
receive  before  using  some  disinfectant  and  deodorizer,  and 
when  used  are  covered  with  air-tight  rubber  covers  and 
taken  away.  Wash  basins  are  emptied  into  slop  pails  that 
can  be  closed  with  rubber  covers  while  conveying  them  to 
the  closets  to  be  emptied  and  cleansed. 

Bed  linen  is  placed  in  a  clean  bag  of  rubber  cloth  and 
conveyed  to  the  laundry.  In  this  way  the  halls,  stairways, 
and  elevator  are  kept  free  from  contamination  and  mal- 
odors. 


INDEX 


Abdominal  incision,  ha3morrhage,  30. 
Abscess,  pelvic,  85. 
Acetic  acid,  104. 
Adenomectomy,  97,  100. 
Adhesions,  not  possible,  25. 

of  appendix  vermiformis,  33. 

of  bladder,  34. 

of  intestines,  33,  52. 

of  omentum,  31,  52, 

of  rectum,  34. 

recent,  35. 

vascular,  old,  55. 
Advantages  of  method,  25,  83,  134. 
Ansesthesia,  64,  77,  119. 
Angioma,  115,  132. 

of  urethra,  113. 
Antisepsis  and  asepsis,  136  et  seq. 
Appendectomy,  57. 
AppendLx  vermiformis,  adhesions,  32. 

treatment,  23. 
Artery,  treatment,  23. 

treatment  of  isolated,  18. 
Aspiration  of  Fallopian  tube,  56. 

Battery  outfits,  14  et  seq. 
Belladonna  tr.,  124. 
Bichloride  of  mercury,  77. 
Bismuth  subgallate,  124. 
Bladder,  adhesions,  34. 

tumors,  102. 

ulcer,  110,  118. 

Cancer,  of  uterus,  65. 

of  cervix,  65,  69. 

of  bladder,  106. 

cures,  83. 
Carbolic  acid,  77. 
Carbuncle,  93. 
Caruncle,  113. 


Case  histories — appendectomy,  60. 

bladder,  neoplasm,  107. 

epithelioma  of  lip,  129. 

Fallopian  tube,  patency,  49,  51. 

fissura  in  ano,  128. 

mammectomy,  3,  97,  99. 

migrated  ligature,  7,  51. 

nasvus,  129. 

nfevus  pilaris,  129. 

ovariotomy,  50,  51. 

post-mortem  condition  of  stump,  6. 
Catgut  ligatures,  objection  to,  1,  25,  96. 

for  peritoneum,  83. 
Caustics,  131. 
Cautery,  galvano,  129. 

knife,  72,  78. 

loop,  69. 
Cervix,  amputation,  45. 
Clamp,  ovariotomy,  35. 

hjemorrhoidal,  121. 
Coagulation  necrosis,  27,  29. 
Cocaine,  127. 
Current,  strength  of,  10,  13,  26,  130. 

length    of    time    to    be    maintained, 
18. 
Cystotomy,  102. 
Cysts,  labial,  87. 

vaginal,  88. 

Directions  for  use  of  instruments,  12. 
Dome  electrode,  75. 

point,  32,  41,  55. 
Doors,  sanitary  construction,  149. 
Drainage  in  pelvic  abscess,  86. 
Dressings,  disposal  of  soiled,  169. 
Dry  dissector,  40. 

Electrolysis,  130. 
Endoscope,  glass,  118,  127. 
171 


172 


ELECTRO-HiEMOSTASIS   IN  OPERATIVE  SURGERY. 


Epithelioma  of  cervix,  69. 

of  skin,  132. 
Experiments,  23,  26,  29. 
Experimental  results,  21,  25,  29. 

Fallopian  tube,  experiments,  26,  29. 

patency,  6,  49,  51,  59. 

operation  upon,  49. 

aspiration,  56. 
Fibroid,  39  et  seq. 
Fissure  of  anus,  125. 
Fissure  of  neck  of  bladder,  118. 
Fistula  of  rectum,  57. 
Flaxseed  tea  enema,  124,  125. 
Floors,  sanitary  construction,  140. 
Forceps,  plain,  9. 

hpemorrhoidal,  121. 

for  ovariotomy,  35. 

shield,  laparotomy,  34. 
elytrotomy,  80. 

the  dome,  32. 

temperature  required,  35. 

time  required,  18. 
Formaldehyde  disinfection,  160  et  seq. 
French  method  for  hysterectomy,  82,  84. 
Friable  tissue,  25,  132. 

Galvano-cautery,  67,  129. 
Glands,  lymphatic,  100. 

of  urethra,  116. 
Glycerin  and  carbolic  for  hands,  59. 
Glycerrhiza  comp.  ext.,  124. 

Healing  process,  23,  30,  107. 
Heat,  10,  104,  152. 
Hsematocele,  pudendal,  92. 
Haemorrhage  in  abdominal  section,  30. 

capillary,  32. 

control  of,  25. 

in  sac  of  Douglas,  32. 

secondary,  18. 

with  cautery  knife,  73,  131. 
Hsemorrhoidal  clamp,  121. 
Haemorrhoids,  120. 
Hernia,  30. 

High  amputation  of  cervix,  71. 
Hospital  construction,  187  et  seq. 
Hydrosalpinx,  52. 
Hysterectomy,  advantage  of  method,  83. 

for  cancer,  abdominal,  65. 
vaginal,  76. 

for  fibroid,  42. 

mortality,  84. 


Instruments,  sterilization,  158. 
Intestine,  adhesions,  33. 

protection  to,  31. 

operation  upon,  23,  57. 

Labial  cysts,  87. 
Laboratory  experiments,  21,  23. 
Ligature,  objections  to,  1,  25,  30,  32,  49. 
Lymphatics,  treatment,  25. 

Maramectomy,  95. 

Mesosalpinx  treatment,  54. 

Mortality  of  method,  84. 

Mucous  surfaces,  treatment,  23,  25,  57. 

Myomectomy,  39. 

Neoplasms,  bladder,  102. 

of  mucous  membranes  and  skin,  129. 
Nerves  are  devitalized,  25. 

Omentum,  adhesions,  32,  52. 

treatment,  31. 
Opii  comp.  liq.,  124. 
Ovariotomy,  30. 
Ovario-salpingectomy,  52. 

Pain,  5,  25,  97,  138. 
Pedicle,  formation,  53. 

forceps,  small,  35. 
large,  36,  37. 

post-operationem,  5. 

repair,  23. 

treatment,  35  et  seq. 
Pelvic  abscess,  85. 
Peritoneum,  37,  45,  72. 

suturing  of,  83. 
Plumbing,  sanitary,  149. 
Preparatory     treatment,     haemorrhoids, 
120. 

major  operations,  156. 
Pudendal  vrounds,  90. 
Pyosalpinx,  54.  • 

Reparative  process,  23,  25,  59,  64,  107, 

122. 
with  ligature,  5. 
Recoveries  incomplete  with  ligature,  49, 

50. 
Rheostat,  12. 

Salpingectomy,  49. 

Septic  processes  inhibited,  25,  60. 

Sequelae,  operative,  unfavorable,  5. 


INDEX. 


173 


Shield  forceps,  40,  80. 
Silk  ligatures  post-operationem,  5. 
Sloughing  from  pressure,  44. 
Soda  bicarbonate,  124. 
Speculum,  Byrne's,  68. 
Sterilizing  effect  of  method,  25. 
Stump  ablation,  58. 

aseptic  conditions,  25. 

exudates,  with  ligature,  50,  59,  60. 

ligation,  6. 

conditions  after  treatment,  19,  63. 

size  after  treatment,  25. 

reparatory  processes,  25. 
Suture  material,  158. 

Temperature  of  heated  forceps,  12. 
Time  necessary  for  desiccation,   18, 

81,  96,  121. 
Transformer,  11. 

Ulcer  of  bladder,  110,  118. 
of  rectum,  125. 


31. 


Ureter,  treatment,  23. 
Urethra,  glands  of,  116. 

papilloma  of,  117. 

stenosis  of,  117. 

Vagina,  cysts  of,  88. 

disinfection  of,  76. 

hysterectomy  through,  76. 

indications  for  section  of,  85. 
Varix  of  vulva,  89. 
Vascular  tumors,  130. 
Vaseline  for  forceps,  13,  36. 
Ventilation,  sterile,  methods  of,  152. 
Vessels,  treatment  of,  in  hysterectomy, 

43. 
Volsellum  forceps  diverging,  72. 
Voltage  required,  11. 
Vulva,  diseases  of,  85. 

Walls,  sanitary  construction,  139. 

Watts  required,  10. 

Windows,  sanitary  construction,  143. 


LIST   OF   AUTHORS   CITED 


Armstrong,  57. 
Barker,  100. 
Beard,  135. 
Bloom,  131. 
Bovee,  51. 
Byrne,  65,  135. 
Chrobak,  50. 
Clark,  65. 
Dickinson,  123. 
Emery,  137. 
Ferguson,  6. 
Haggard,  55. 


Keith,  7,  49. 
Kelly,  4,  47,  65. 
Pignolet,  8. 
Randolph,  165. 
Ries,  49. 
Routh,  88. 
Schauta,  50. 
Schleich,  64. 
Seymour,  23. 
Smith,  57. 
Van  Buren,  125. 
Wilson,  160. 


THE    EFD 


UNIVERSITY  LIBRARIES  (hsi.stx) 

5»^c.c  .n  nnerative_sur_gerv 


2002190761 


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